Pediatric Care Information

Pediatric Care Information for Providers

One of our primary goals is to ensure that all our members, and especially our youngest members, receive the preventive care they need from their providers.

Well-Child Visits

We will continually provide materials and resources to help our participating providers complete Child and Adolescent Well-Child Visits for their patients in Health Partners (Medicaid) and CHIP plans.

Well-Child Visit Timeline

Your patients are eligible for a well-child visit once every year, even if 365 days have not yet passed since their last well-child visit in the prior calendar year. Providers will be reimbursed as long as it is a new calendar year.

Well-Child Visit	Next Well Visit	Reimbursable under Guidelines
January 1, 2023	December 30, 2023	No
February 1, 2023	January 15, 2024	Yes

Combined Sick Visits and Well-Child Visits

Your office can submit claims for both a sick visit and a preventive well-child visit for services provided on the same day, provided that the Modifier 25 is added to the claim if appropriate.

Please note the following coding reminders/clarifications:

• As necessary, modifier 25 should be billed in the first modifier position with the applicable E&M code for the allowed sick visit. If modifier 25 is not billed in the first position, the sick visit may be denied.

• Providers can bill the age-appropriate preventive CPT codes (99381-99385, 99391, 99392- 99395), and 99461) and a separate identifiable E&M code with the modifier 25, when appropriate.

• Well-child visits can be reported with the following diagnosis codes: Z00.00, Z00.01, Z00.5, Z00.8, Z00.110, Z00.111, Z00.121, Z00.129, Z02.0-Z02.6, Z02.71, Z02.82, Z76.1, and Z76.2.

• Appropriate diagnosis codes must be billed for the respective well-child visit and sick visit.

Examples of Proper Coding

E&M Example	Well-child Visit Diagnosis Code (in the primary position)	Well-child Visit E&M Code	Allowable sick visits with Modifier 25 (when billing with a well-child visit)
a. New Patient E&M visit	Z00.121	99382	99202-25
b. Established Patient E&M visit	Z00.121	99392	99212-25
c. Established Patient E&M visit	Z00.129	99394	99213-25

Note: Providers must have proper medical record documentation to support the CPT codes and the E/M codes billed. This documentation should be able to be separated into two distinct notes that will support both E/M services billed for the visit.

Well Child Visit Tools

CDC’s Developmental Milestones – available in English and Spanish
Developmental Milestone Resources for WIC Programs – available in English and Spanish
Penn State Extension: ABCs of Growing Healthy Kids – available in English and Spanish

Quality Care

Clinical and Quality Resources

We have created a Comprehensive Pediatric Education Kit that includes the following resources:

Jefferson Health Plans Programs and Initiatives

Jefferson Health Plans currently makes monthly automated phone calls for the following:

Pediatric Birthday Calls (monthly) — outreach calls are made 60 days before the member’s birthday to remind them to schedule their appointment and reminds members what screenings they may need based on their age.

Pediatric Overdue PCP Visits (monthly) — outreach calls to remind families/members that they are overdue for a PCP visit.

Pediatric Overdue Lead Screening (quarterly) — call reminder to families/caregivers that members are overdue for lead screening.

Asthma (quarterly for Medicaid, monthly for CHIP) — calls are made to the asthma population regardless of age to remind them about potential symptom triggers, medications as needed, scheduling PCP visits and getting the flu shot.

Quality Outreach

Our members/your patients may receive outreach from one of the following resources to assist them with appointment scheduling, preventive health reminders and/or care coordination:

Internal Quality Campaigns
Jefferson Health Plans has a team of Quality Outreach Representatives who contact members proactively to help close care gaps and help them schedule appointments as needed.

Block Scheduling Events
Jefferson Health Plans can assist with outreach and scheduling for collaborative events at the PCP office. Please let your Network Market Manager know if you are interested and they can provide additional details. We will take every request into consideration, as long as they meet the minimum criteria, but can’t make any promises until they consult with the QIP team.

Carenet
A third-party vendor that contracts with Jefferson Health Plans to do telephonic outreach to members to help schedule visits or remind them to close care gaps.

Healthy Measures
A third-party vendor that contracts with Jefferson Health Plans to do in-home visits and provide services at health events. Healthy Measures can perform lead screenings for our youngest members.

Clark Resources:
A third-party call center that contracts with Jefferson Health Plans to engage members who need preventive dental services and help them schedule a visit.

Referrals for Case Management/Care Coordination Services

If you have members who you feel may benefit from case management services, please refer them to our JHP Clinical Programs teams.

How to refer a member for case management:

Contact us at 1-866-500-4571 option #2.
Email ClinicalConnections@jeffersonhealthplans.com using the Clinical Resources Forms.
Fax the Clinical Programs Provider Referral form to 215-845-4181.

Other Resources

The following tools may be helpful resources to use before, during or after a well visit.