EPSDT well-child providers: new reimbursement rates, and guidance for new billing requirements

Washington State Health Care Authority sent this bulletin at 01/13/2025 07:15 AM PST

January 13, 2025

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New reimbursement rates for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) well-child providers

The Health Care Authority (HCA) implemented new reimbursement rates for developmental and behavioral health screening as a part of ongoing efforts to improve access to high-quality health care for children and families.

These enhanced rates support providers in delivering comprehensive preventive health care for children via timely routine screenings. Developmental and behavioral health screenings play a critical role in the identification of conditions that can impact development and lifelong health.

Reimbursement rate changes

Screening type	06/01/2023 – 12/31/2023	01/01/2024 – 06/01/2024	01/01/2025 – 06/30/2025
Developmental (96110)	$6.45	$12.90	$13.80
Behavioral health (96127)	$2.85	$5.70	$11.20
Behavioral health (96160)	$1.71	$3.42	$11.20
Caregiver depression (96161)	$1.71	$3.42	$10.29

HCA’s billing guides and fee schedules provides further guidance on how to submit claims and current fee schedules.

Developmental and behavioral health screening claims: guidance for new billing requirements

HCA provided guidance for new billing requirements for developmental and behavioral health screenings starting July 1, 2025. These changes affect providers conducting well-child checkups for children enrolled in Apple Health (Medicaid).

In order to be reimbursed for claims with dates of service on or after July 1, 2025, Apple Health providers must submit the appropriate (CPT®) code for developmental and behavioral health screening, accompanied by both:

A modifier to indicate the outcome of the screening
An ICD-10-CM diagnosis code to indicate the type of screening

Next steps

Review the EPSDT well-child program billing guide for billing guidance related to these requirements.
Work with your organization and billing staff to determine necessary updates to your electronic health records and billing processes.

View EPSDT's well-child program billing guide

Contact

Email the Apple Health clinical inbox with questions.

Visit EPSDT's webpage

About the Health Care Authority (HCA)

Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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The Washington State Health Care Authority (HCA) complies with all applicable federal and Washington state civil rights laws and is committed to providing equal access to our services. Visit HCA’s website to view complete nondiscrimination statements.