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11 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> b. Provider(s) shall verify each Medicaid or NCHC beneficiary's eligibility <br /> each time a service is rendered. <br /> c. The Medicaid beneficiary may have service restrictions due to their <br /> eligibility category that would make them ineligible for this service. <br /> d. Following is only one of the eligibility and other requirements for <br /> participation in the NCHC Program under GS 108A-70.21(a): Children must <br /> be between the ages of 6 through 18. <br /> 2.1.2 Specific <br /> a. Medicaid <br /> None Apply. <br /> b. NCHC <br /> None Apply. <br /> 2.2 Special Provisions <br /> 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a <br /> Medicaid Beneficiary under 21 Years of Age <br /> a. 42 U.S.C. § 1396d(r) [1905(r)of the Social Security Act] <br /> Early and Periodic Screening,Diagnostic, and Treatment(EPSDT)is a <br /> federal Medicaid requirement that requires the state Medicaid agency to <br /> cover services,products, or procedures for Medicaid beneficiary under 21 <br /> years of age if the service is medically necessary health care to correct or <br /> ameliorate a defect,physical or mental illness, or a condition [health <br /> problem] identified through a screening examination" (includes any <br /> evaluation by a physician or other licensed clinician). <br /> This means EPSDT covers most of the medical or remedial care a child <br /> needs to improve or maintain his or her health in the best condition possible, <br /> compensate for a health problem,prevent it from worsening, or prevent the <br /> development of additional health problems. <br /> Medically necessary services will be provided in the most economic mode, <br /> as long as the treatment made available is similarly efficacious to the service <br /> requested by the beneficiary's physician,therapist,or other licensed <br /> practitioner; the determination process does not delay the delivery of the <br /> needed service; and the determination does not limit the beneficiary's right to <br /> a free choice of providers. <br /> EPSDT does not require the state Medicaid agency to provide any service, <br /> product or procedure: <br /> 1. that is unsafe,ineffective, or experimental or investigational. <br /> 2. that is not medical in nature or not generally recognized as an accepted <br /> method of medical practice or treatment. <br /> Service limitations on scope, amount, duration, frequency, location of <br /> service, and other specific criteria described in clinical coverage policies may <br /> be exceeded or may not apply as long as the provider's documentation shows <br /> that the requested service is medically necessary"to correct or ameliorate a <br /> defect,physical or mental illness, or a condition" [health problem]; that is, <br /> provider documentation shows how the service,product, or procedure meets <br /> 20A 13 5 <br />