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Back  RFI # 188: 837 Prof - EPSDT

Formal vs. Informal Help Informal Formal

Submitter

becky ramaeker

Description

Please provide an interpretation regarding the relationship between the 2400 SV111 and 2300 CRC segment when CRC01=ZZ. Should the 2300 CRC EPSDT Referral segment be required when 2400 SV111 = Y? Required for all patients when SV111 = Y, or just Medicaid patients?

Response

The implementation guide does not establish a semantic relationship between the 2300 EPSDT CRC and the SV111. The EPSDT CRC is required on EPSDT claims. The SV111 is required when Medicaid services are the result of a screening referral.

Example:

The patient comes in explicitly to receive the screening. During the screening, the physician determines there may be a vision problem and orders/refers follow-up with an opthamologist. The claim for this visit would include the CRC indicating the visit WAS FOR a screening and a reason code indicating the screening resulted in a referral for additional treatment.

After the opthamologist performed his/her examination, that claim would use SV111 to indicate the line items were provided AS A RESULT OF an EPSDT screening referral. The Opthamologist visit is not considered to be an EPSDT service itself and therefore would not be cause for using the 2300 EPSDT CRC.
Submission 2/3/2005
Status Date 4/1/2005
Status F - Final
Primary References
Document 004010X098A1
SectionAddenda
Page37
Set ID837P
Table2
Loop2300
Segment Position220
Segment IDCRC
Element Position01
Secondary References
RFI ID 153
Document 004010X098A1
SectionAddenda
Page55
Set ID837P
Table2
Loop2400
Segment Position370
Segment IDSV1
Element Position11