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PROVIDER MANUAL
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Section #
Title
Updated
Title Page
MISSION & GOAL OF THE PROGRAM
2016
Section 1
INTRODUCTION: MARYLAND HEALTHY KIDS/EPSDT PROGRAM
2016
A
Overview
2016
B
Healthy Kids Program Administration
2015
C
Provider Certification & Qualifications
2016
D
Local Health Departments' Role
2014
E
Managed Care Organizations
2016
F
Healthy Kids Program Performance Improvement Standards
2014
G
HIPAA Privacy
2014
Section 1
ADDENDUM
2016
1.1
Provider Application for Certification & Participation
2017
1.2
Provider Certification Letter
2015
1.3
Provider Action Grid for MCO Newborn Coordinators
2003
1.4
HIPAA Letter by Maryland Attorney General
2003
Section 2
MARYLAND EPSDT PREVENTIVE HEALTH CARE SCHEDULE
2020
A
Initial Screening Services
2016
B
Periodic Screening Services
2016
C
Additional Screening Services
2016
D
Hearing, Vision & Dental Screening Services
2016
E
Required EPSDT Components of the Maryland Healthy Kids Program
2016
Section 2
ADDENDUM: MARYLAND HEALTHY KIDS PREVENTIVE HEALTH SCHEDULE
2020
Section 3
HEALTHY KIDS SCREENING COMPONENTS
2017
A
Health and Developmental History
2016
B
Comprehensive Physical Examination Requirement
2016
C
Laboratory Tests
2016
D
Immunizations
2017
E
Health Education Anticipatory Guidance
2016
Section 3
CHARTS AND TABLES
2016
Chart 1
Primary Teeth Eruption
2015
Chart 2
Permanent Tooth Eruption
2015
Table 1
Girls Systolic BP by Age & Height
2015
Table 2
Boys Systolic BP by Age & Height
2015
Table 3
Dietary Fluoride Supplement Dosage Schedule
2014
Table 4
DHMH List of Disorders on the Newborn Screen
2016
Table 5
Hematocrit & Hemoglobin Values for Children
2015
Table 6
MD Elevated Blood Lead Diagnostic & Follow-up Schedule for Children
2014
Table 7
MD Department of Environment: Case Coordination Guidelines for Lead Poisoned Children
2014
Table 8
Targeted Testing & Treatment of Latent TB Infection
2014
Table 9
Tuberculin Skin Test Cut-Points by Age for Low Risk Persons
2014
Table 10
Regimens for Treatment of Latent TB Infections
2014
Table 11
Classification of Cholesterol Levels in Children and Adolescents
2014
Section 3
ADDENDUM
2016
3.1
Developmental Screening Tools
2014
3.2
Additional Evaluation & Intervention for Developmental Disorders
2014
3.3
Modified Checklist for Autism in Toddlers-Revised, with Follow up (MCHAT-R/F)
2015
3.4
Early Hearing Detection & Intervention Guide
2015
3.5
Jaeb Visual Acuity Screener
2016
3.6
MD WIC Program Medical Documentation Form
2015
3.7
Expert Committee Recommendations for the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity-2007-An Implementation Guide from the Childhood Obesity Action Network
2007
Section 4
ADOLESCENT PREVENTIVE HEALTH
2016
A
A. Introduction
2016
B
B. Health and Developmental History
2015
C
C. Comprehensive Physical Examination
2015
D
D. Laboratory Tests
2016
E
E. Immunizations
2016
F
Health Education and Anticipatory Guidance
2015
Section 4
ADDENDUM
2015
4.1
HEEADSSS Psychosocial Interview
2015
4.2
Identify and Treat Adolescent Depression
2010
4.3
Patient Health Questionnaire Modified for Teens (PSC-Y)
2015
4.4
Pediatric Symptoms Checklist for Teens (PHQ-9 Modified)
2015
4.5
Informed Consent to HIV Testing (English & Spanish)
2007
Section 5
OTHER CHILD HEALTH-RELATED SERVICES
2016
A
Expanded EPSDT-Related Services
2016
B
HealthChoice Self-Referred Services
2016
C
Children in State-Supervised Care
2016
D
Other Programs for Children
2016
E
Dental Care
2015
F
Public Mental Health System (PMHS)
2016
Section 5
ADDENDUM
2020
5.1
Maryland Uniform Consultation Referral Form
2015
5.2
School-Based Health Center Health Visit Report Form
2015
5.3
Local Infants and Toddlers Referral and Feedback Form
2009
5.4
Local Health Services Request Form
2015
5.5
Instructions for Use of Local Health Services Request Form
2015
5.6
REM Intake Application
2015
Section 6
BILLING AND ENCOUNTER DATA REPORTING
2017
A
Introduction
2015
B
Eligibility Verification
2015
C
General Rules for Medical Assistance Billing
2016
D
Billing for Fluoride Varnish Application as Part of the EPSDT Preventive Care Visit
2016
E
Billing for Vaccines for Children Program
2017
F
Billing for Services in State-supervised Care
2015
G
Billing for Services to Children in Managed Care Organizations (MCOs)
2015
H
Billing for Services to Children Non in MCO (Fee-For-Service)
2017
I
CMS-1500 Billing Instructions
2016
Section 7
APPENDICES
2016
7.1
APPENDIX: PREVENTIVE CARE FORMS
2015
7.1.1
Age Specific Encounter Forms
2014
7.1.2
Body Mass Index (BMI) Calculator-Child and Teen
2016
7.1.3
WHO & CDC Growth Charts
2014
7.1.4
Medical Family History Questionnaire (English)
2006
7.1.5
Medical Family History Questionnaire (Spanish)
2006
7.1.6
Objective Hearing and Vision Testing Forms
2016
7.2
APPENDIX:RISK ASSESSMENT FORMS
2016
7.2.1
CRAFT Adolescent Substance Abuse Assessment (English)
2019
7.2.2
CRAFT Adolescent Substance Abuse Assessment (Spanish)
2019
7.2.3
Mental Health Questionnaires (English & Spanish)
2014
7.2.4
Nutrition Questionnaires (Infant, Child, Adolescent)
2014
7.2.5
Preventive Screen Questionnaire: Lead, TB, Anemia, Cholesterol & STD/HIV (English)
2017
7.2.6
Preventive Screen Questionnaire: Lead, TB, Anemia, Cholesterol & STD/HIV (Spanish)
2017
7.2.7
SEEK Questionnaire (Abuse Assessment) (English)
2014
7.2.8
SEEK Questionnaire (Abuse Assessment) (Spanish)
2014
7.2.9
Victimization Scale (English)
2015
7.2.10
Victimization Scale (Spanish)
2015
7.3
APPENDIX: IMMUNIZATION FORMS & RESOURCES
2017
7.3.1
Maryland Immunization Certification Form
2014
7.3.2
Maryland Recommended Childhood & Adolescent Immunization Schedules
2019
7.3.3
Maryland Combination Vaccines Schedule
2017
7.3.4
Parental Delegation Form for Minors
2015
7.3.5
VFC Vaccine Inventory Form
2015
7.3.6
VFC Log of Children Receiving VFC Vaccines
2013
7.3.7
Patient Eligibility Screening Record
2015
7.3.8
VFC Program Contact Center
2016
7.3.9
VFC Vaccine Administration Record
2017
7.3.10
VFC Vaccine Return & Wastage Form
2015
7.3.11
Temperature Log for Refrigerator-Celsius
2017
7.3.12
Temperature Log for Refrigerator-Fahrenheit
2017
7.3.13
Temperature Log for Freezer-Celsius
2017
7.3.14
Temperature Log for Freezer-Fahrenheit
2017
7.4
APPENDIX: HEALTH EDUCATION MATERIALS
2017
7.4.1
Zika-Information-Flyer
2017
7.4.2
MDH Zika Factsheet
2017
7.4.3
Communicative Diseases Factsheet
2011
7.4.4
General Child Seat Use & MD Child Safety Seat Law
2013
7.4.5
My Plate
2015
7.4.6
National Safe Kids Campaign Materials-Bike
2013
7.4.7
National Safe Kids Campaign Materials-Fire
2013
7.4.8
National Safe Kids Campaign Materials-Gun
2013
7.4.9
National Safe Kids Campaign Materials-Poison
2014
7.4.10
National Safe Kids Campaign Materials-Water
2013
7.4.11
CDC Tuberculosis Training Materials Order Form
2015
7.4.12
Center for Immunization Health Education Materials Order Form
2014
7.4.13
DHMH Office of Oral Health Printed Materials Request Form
2015
7.4.14
HIV/AIDS Prevention Materials Order Form
2015
7.4.15
Kids in Safety Seats Education Materials Order Form
2013
7.4.16
Lead Poisoning Prevention Program Educational Materials Order Form
2008
7.4.17
Maternal & Child Health Bureau Publication Order Form
2013
Section 8
TELEPHONE DIRECTORIES
2016
A
Healthy Kids Consultants
2017
B
Local Departments of Social Services
2014
C
Local Domestic Violence Directory
2014
D
Local Health Departments Administrative Care Coordination Units
2019
E
Local Health Departments Children's Health Program (MCHP)
2015
F
Local Health Departments Nursing Lead Contacts
2014
G
Local Health Departments TB Control Coordinators
2014
H
Local Protective Services
2014
I
Maryland Head Start
2015
J
Maryland Health Connection Connector Entities
2014
K
Maryland Local WIC Agencies
2014
L
Maryland VFC Contact Center
2015
M
Medicaid Administration & Billing Contacts
2015
N
Medicaid HealthChoice Managed Care Organization Resource List
2015
O
Medicaid HealthChoice Managed Care Organization Pharmacy Benefit Managers
2014
P
Medicaid Transportation Grant Program Local Transportation Managers
2019
Q
MSDE Local Child Find Programs
2015
R
MSDE Local Infants & Toddlers Programs
2016
S
REM Contact Information
2016
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