Common use of EPSDT Audit Clause in Contracts

EPSDT Audit. In conjunction with the medical audit, complete EPSDT claims data for the Contractor and a sample of medical records will be evaluated by the Division to determine compliance by the Contractor with the requirements of this Contract for provision of EPSDT Services to Enrollees under age twenty-one (21). The Contractor must achieve a screening rate of eighty-five percent (85%) and an immunization rate of ninety percent (90%) in order to be in compliance with this contract. For a child who has been enrolled from birth through 12 months, compliance with the EPSDT periodicity schedule is six (6) screens. Immunization compliance means that the child is up to date with his/her immunizations based on the ACIP immunization schedule. The Contractor shall bear no refund obligation related to this section during the initial contract period. For all renewal periods following the initial contract period, failure to achieve the above screening rate shall require the Contractor to refund to the Division the following amount: • Achievement of <85% screening and 90% immunization rate (the lowest rate shall be considered to be the rate for both screenings and immunizations) will require a refund of $10 per Enrollee for all Enrollees under age 12 mos. • The Division will publish the achievement of screening rates of eighty-five percent (85%) or greater to the Medicaid population and the medical community in the applicable service area. The Division will require its Contractor to make all screening rates known to potential enrollees in required educational and marketing presentations.

EPSDT Audit. In conjunction with the medical audit, complete EPSDT claims data for the Contractor and a sample of medical records will be evaluated by the Division to determine compliance by the Contractor with the requirements of this Contract for provision of EPSDT Services to Enrollees under age twenty-one (21). The Contractor must achieve a screening rate of eighty-five percent (85%) and an immunization rate of ninety percent (90%) in order to be in compliance with this contract. For a child who has been enrolled from birth through 12 months, compliance with the EPSDT periodicity schedule is six (6) screens. Immunization compliance means that the child is up to date with his/her immunizations based on the ACIP immunization schedule. The Contractor shall bear no refund obligation related to this section during the initial contract period. For all renewal periods following the initial contract period, failure to achieve the above screening rate shall require the Contractor to refund to the Division the following amount: •  Achievement of <85% screening and 90% immunization rate (the lowest rate shall be considered to be the rate for both screenings and immunizations) will require a refund of $10 per Enrollee for all Enrollees under age 12 mos. •  The Division will publish the achievement of screening rates of eighty-five percent (85%) or greater to the Medicaid population and the medical community in the applicable service area. The Division will require its Contractor to make all screening rates known to potential enrollees in required educational and marketing presentations.