CMS416InstructionsUpdated508

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
PRA Disclosure Statement: Annual completion of the Form CMS-416 is mandatory for states
pursuant to section 1902(a)(43)(D) of the Social Security Act which requires states to annually
report on the provision of Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
services. Under the Privacy Act of 1974 any personally identifying information obtained will be
kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is xxxx (expiration date xxxx). The time required
to complete this information collection is estimated to average 29 hours per response including
the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
A. Purpose -- The annual EPSDT report (form CMS-416) provides basic information on
participation in the Medicaid child health program. The data are used to assess the effectiveness of
state Medicaid programs in reaching EPSDT eligible children in terms of the number of individuals
under the age of 21 (by age group and basis of Medicaid eligibility) who are provided child health
screening services, referred for corrective treatment, and receiving dental services. Child health
screening services are defined for purposes of reporting on this form as initial or periodic screens
required to be provided according to a state’s screening periodicity schedule.
The completed report demonstrates the state’s attainment of its participation and screening goals.
Participation and screening goals are two different standards against which EPSDT performance
(or penetration) is measured on the form CMS-416. From the completed reports, trend patterns
and projections are developed for the nation and for individual states or geographic areas, from
which decisions and recommendations can be made to ensure that eligible children are given the
best possible health care. The information is also used to respond to congressional and public
inquiries.
B. Reporting Requirement -- Each state that supervises or administers a medical
assistance program under Title XIX of the Social Security Act must report annually on form
CMS-416. These data must include services reimbursed directly by the state under fee-forservice, or through managed care, prospective payment, or other payment arrangement or
through any other health or dental plans that contract with the state. Each state is required to
collect encounter data (or other data as necessary) from managed care and prospective payment
entities in sufficient detail to provide the information required by this report. States may contact
the state lead in their CMS office or the EPSDT technical assistance mailbox,
[email protected], if technical assistance is needed to complete this form.
C. Effective Date –These associated revised instructions must be used starting with the
reporting period federal fiscal year 2023, beginning October 1, 2022 through September 30, 2023,

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
for data due to CMS on the Form CMS-416 on or before April 1, 2024.
D. Submittal Procedure -- States should submit the annual Form CMS-416 and the state
medical and dental periodicity schedules electronically to the CMS central office via the EPSDT
technical assistance mailbox at [email protected]
E. not later than April 1 of the year following the end of the federal fiscal year being
reported.
The electronic form and instructions are available on the CMS website at:
https://www.medicaid.gov/medicaid/benefits/epsdt/index.html.
States may not modify the electronic form or submit variations of the form; it must be submitted as
downloaded from Medicaid.gov: https://www.medicaid.gov/medicaid/benefits/downloads/form416.zip
States that have data limitations or that have made program changes during a reporting period
that significantly impact data results, such as a change in the periodicity schedule to follow the
most recent version of the American Academy of Pediatrics’ Bright Futures™ guidelines, may
include a brief note with the cover correspondence accompanying their CMS-416 submission.
This information will be included in a separate footnotes document on the Medicaid.gov website,
accompanying the national and state data reports.
F. Detailed Instructions -- Enter your state name and the federal fiscal year as
directed below.
State -- Enter the name of your state using the two character state code in upper case format.
Fiscal Year -- Enter the federal fiscal year (FFY) being reported in YYYY format.
Note: The federal fiscal year is from October 1 through September 30. For example, FFY 2023 is
October 1, 2022 through September 30, 2023.
CMS Generated Reporting of State Form CMS-416 Using T-MSIS -- In an effort to reduce
state reporting burden, CMS has developed the capacity to generate state-specific Form CMS416 reports using state-reported data to CMS via the Transformed Medicaid Statistical
Information System (T-MSIS). This option is available only to states that are current with TMSIS data submissions and pass T-MSIS benchmarks for data quality and completeness. If your
state gives CMS permission to generate Form CMS-416 data using T-MSIS, please enter an “X”
in the space provided on the form, along with the two digit state code and the federal fiscal year.
The rest of the form should remain blank. The form and copies of the state’s current medical
and dental periodicity schedules should be submitted to CMS by April 1st via the EPSDT
technical assistance mailbox. States that select this option will be given an opportunity to review
and validate the T-MSIS generated report before it is finalized and made publicly available.

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
States that choose not to have CMS generate the state-specific Form CMS-416 or who do
not meet the criteria to have CMS generate the Form CMS-416 should follow the detailed
instructions for the completion of the Form CMS-416.
For each of the following line items, report total counts by the age groups indicated and if
categorically or medically needy (described below). In cases where calculations are
necessary, perform separate calculations for the total column and for each age group. You
must enter a number in each line and column of data requested even if the number is
“0.”
Important Reporting Requirements:
• Report age based upon the individual’s age as of September 30 of the reporting year.
• Report all data in the age category reflecting the individual’s age at the end of the federal
fiscal year even if the individual received services in two age categories. For example, if a
child turned age 3 on September 1st, but received EPSDT services at age 2, these services
would be counted in the age 3-5 category.
• The population for which the data is reported on Lines 3a –14 are children from Line 1b, that
is unduplicated counts of individuals enrolled for at least 90 continuous days during the
reporting period.
• The objective of CMS-416 reporting is to capture on each line all services that were
provided, regardless of payment status and unduplicated by child. Report data based on visits
during which a service was provided to an eligible individual during the reporting period,
according to the instructions for each line, regardless of whether the unduplicated claim was
paid, unpaid, or denied. States must be able to ensure that once a service is reported on the
CMS-416, it is not reported again in any reporting period if payment status changes, for
example, from unpaid to paid.
• Do not enter any data into the greyed-out cells.
Categorically Needy (CN) and Medically Needy (MN) Eligibility Groups -- For purposes of
reporting data on the CMS-416, children should be reported as medically needy (with or without
spend down) or categorically needy (not medically needy) based on their eligibility status as of
September 30th of the reporting federal fiscal year. If they weren’t enrolled in Medicaid on
September 30th because their eligibility was terminated prior to this date, their status should be
reported as of the date they were terminated. States should determine the basis of eligibility
consistent with the instructions from the T-MSIS Data Dictionary, in consultation with state
Medicaid eligibility officials, if needed.
Line 1a -- Total Individuals Eligible for EPSDT -- Enter the total unduplicated number of
individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program
(CHIP) Medicaid expansion program determined to be eligible for EPSDT services, distributed by
age and by basis of eligibility (i.e., CN or MN) as of September 30. If a child was not enrolled in
Medicaid on September 30th because their eligibility was terminated prior to this date, the child
should still be included on this line. Their age should be reported as of September 30th of the reporting
year, while their basis of eligibility should be reported as of the date they were terminated.

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
“Unduplicated” means that an eligible person is reported only once, although he/she may have had
more than one period of eligibility during the year, and that a claim for a service that was provided
is only counted once, whether the claim was unpaid, paid, or denied. Include all individuals
regardless of whether the services are provided under fee-for-service, prospective payment,
managed care, or other payment arrangements. Medicaid-eligible individuals under age 21 are
considered eligible for EPSDT services regardless of whether they have been informed about the
availability of EPSDT services or whether they accept EPSDT services at the time of informing.
Individuals for whom third-party liability is available should also be counted in the number.
Do not include in this count the following groups of individuals:
•
•

•
•
•

Medically needy individuals under the age of 21 if your state does not provide EPSDT
services for the medically needy group;
Individuals eligible for Medicaid only under a Section 1115 waiver as part of an
expanded population for which the full complement of EPSDT services is not
available;
Undocumented aliens who are eligible only for emergency Medicaid services;
Children in separate state CHIP programs; or
Other groups of individuals under age 21 who are eligible only for limited services as
part of their Medicaid eligibility (for example, pregnancy-related services).

Line 1b -- Total Individuals Eligible for EPSDT for 90 Continuous Days -- Enter the total
unduplicated number of individuals under the age of 21 from Line 1a who have been continuously
enrolled in Medicaid or a CHIP Medicaid expansion program for at least 90 continuous days in the
federal fiscal year and determined to be eligible for EPSDT services, distributed by age and by
basis of eligibility. For example, if an individual was enrolled from October 1 to November 30
and again from August 1 to September 30, the individual would not be considered eligible for 90
continuous days in the federal fiscal year.
Line 1c -- Total Individuals Eligible for EPSDT under a CHIP Medicaid Expansion
Program -- Enter the total unduplicated number of individuals included in Line 1b who are
under the age of 21 and eligible for EPSDT services as part of a CHIP Medicaid expansion
program. For children who have been eligible for EPSDT under both Medicaid and a CHIP
Medicaid expansion program during the report year, include the child on this line if they are
enrolled in a CHIP Medicaid expansion as of September 30.
Line 2a -- State Periodicity Schedule -- Enter the number of initial or periodic general health
screenings required to be provided to individuals within the age group specified according to
the state’s medical periodicity schedule. (Example: If your state’s periodicity schedule requires
screening at 12, 15, 18, 24, and 30 months, the number 5 should be entered in the 1-2 age
group column.) Make no entry in the total column.

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
If your state follows the 2019 American Academy of Pediatrics’ Bright Futures™ guidelines, the
periodicity schedule should be reported on the form as follows:
Age
Group
<1
7

Age
Group
1-2
5

Age
Group
3-5
3

Age
Group
6-9
4

Age
Group
10-14
5

Age
Group
15-18
4

Age
Group
19-20
2

Note: As noted above , use the state’s current medical periodicity schedule to complete Line
2a and submit a copy of the state’s current medical and dental periodicity schedules to CMS
with your CMS-416 submission.
Line 2b -- Number of Years in Age Group -- Make no entries on this line. This is a fixed
number reflecting the number of years included in each age group.
Line 2c -- Annualized State Periodicity Schedule -- Make no entries on this line. This line
is auto-calculated by dividing the values on Line 2a by the numbers on Line 2b. This is the number
of screenings expected to be received by an individual in each age group in one year.
Line 3a -- Total Months of Eligibility -- Enter the total months of eligibility for the individuals in
each age group in Line 1b during the reporting year. An individual child should only be counted
once in the age group the individual is in as of September 30. Include the total months of
eligibility in the age category where the individual is reported, even if the individual had
months of eligibility in two age categories during the reporting period. For example, if an
individual was eligible for 12 months, from October 1st through September 30th, but
turned age 3 on August 1st, all 12 months of eligibility would be counted in the age 3-5
category.
Line 3b -- Average Period of Eligibility -- Make no entries on this line. This line is autocalculated by dividing the values on Line 3a by the numbers on Line 1b, and dividing that
number by 12. This number represents the portion of the year that individuals remained
eligible for EPSDT services during the reporting year.
Line 4 -- Expected Number of Screenings per Eligible -- Make no entries on this line.
This line is auto-calculated by multiplying Line 2c by Line 3b. This number reflects the expected
number of initial or periodic screenings per individual under age 21 per year based on the number
required by the state-specific periodicity schedule and the average period of eligibility.
Line 5 -- Expected Number of Screenings -- Make no entries on this line. This line is
auto-calculated by multiplying Line 4 by Line 1b. This reflects the total number of initial or
periodic screenings expected to be provided to the eligible individuals in Line 1b.
Line 6 -- Total Screens Received -- Enter the total number of initial or periodic screens
furnished to eligible individuals from Line 1b under fee-for-service, prospective payment,

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
managed care or other payment arrangements, based on an unduplicated paid, unpaid, or denied
claim.
Note: States may use the CPT codes listed below as a proxy for reporting these initial or periodic
screens. Use of these proxy codes is for reporting purposes only. States must continue to ensure
that all five age-appropriate elements of an EPSDT screen, as defined by law, are provided to
EPSDT recipients.
This number should not reflect sick visits or episodic visits provided to the enrolled
individual unless an initial or periodic screen was also performed during the visit. However,
it may reflect a screen outside of the normal state periodicity schedule that is used as a "catch-up"
EPSDT screening. (A catch-up EPSDT screening is defined as a complete screening that is
provided to bring an individual child up-to-date with the state's screening periodicity schedule. For
example, a child who did not receive a periodic screen at age five visits a provider at age 5 years
and 4 months. The provider may use that visit to provide a complete age appropriate screening and
the screening may be counted on the CMS-416.) Report all screening data in the age category
reflecting the individual’s age at the end of the federal fiscal year even if the individual
received services in two age categories. For example, if a child turned age 3 on September
1st, but had a 30-month well-child visit the previous March, the 30-month visit would be
counted in the age 3-5 age category. Use the codes below or other documentation of such
services furnished under capitated or prospective payment arrangements. The codes to be used to
document the receipt of an initial or periodic screen are as follows:
CPT-4 codes: Preventive Medicine Services *
99381 New Patient under one year
99382 New Patient (ages 1-4 years)
99383 New Patient (ages 5-11 years)
99384 New Patient (ages 12-17 years)
99385 New Patient (ages 18-39 years)
99391 Established patient under one year
99392 Established patient (ages 1-4 years)
99393 Established patient (ages 5-11 years)
99394 Established patient (ages 12-17 years)
99395 Established patient (ages 18-39 years)
99460 Initial hospital or birthing center care for normal newborn infant
99463 Initial hospital or birthing center care of normal newborn infant (admitted/discharged same
date)
*These CPT codes do not require use of a “Z” code.
OR
CPT-4 code s: Evaluation and Management Codes **
99202-99205 New Patient
99213-99215 Established Patient

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
** These CPT-4 codes must be used in conjunction with the following Z codes:
Z76.2 (Encounter for health supervision and care of other healthy infant and child)
Z00.121 (Encounter for routine child health examination with abnormal findings)
Z00.129 (Encounter for routine child health examination without abnormal findings)
Z00.110 (Health examination for newborn under 8 days old)
Z00.111 (Health examination for newborn 8 to 28 days old)
Z00.00-01 (Encounter for general adult medical examination without/with abnormal findings)
Z02.0 (Encounter for examination for admission to educational institution)
Z02.1 (Encounter or pre-employment examination)
Z02.2 (Encounter for examination for admission to residential institution)
Z02.3 (Encounter for examination for recruitment to armed forces)
Z02.4 (Encounter for examination for driving license)
Z02.5 (Encounter for examination for participation in sport)
Z02.6 (Encounter for insurance purposes)
Z02.81 (Encounter for paternity testing)
Z02.82 (Encounter for adoption services)
Z02.83 (Encounter for blood-alcohol and blood-drug test)
Z02.89 (Encounter for other administrative examinations)
Z00.8 (Encounter for other general examination)
Z00.6 (Encounter for examination for normal comparison and control in clinical research
program)
Z00.5 (Encounter for examination of potential donor of organ and tissue)
Z00.70 (Encounter for examination for period of delayed growth in childhood without abnormal
findings)
Z00.71 Encounter for examination for period of delayed growth in childhood with abnormal
findings)
Line 7 -- Screening Ratio -- Make no entries on this line. This line is auto-calculated by
dividing the actual number of initial and periodic screening services received (Line 6) by the
expected number of initial and periodic screening services (Line 5). This ratio indicates the extent
to which EPSDT eligibles received the number of initial and periodic screening services required
by the state's periodicity schedule, prorated by the proportion of the year for which they were
EPSDT eligible.
Line 8 -- Total Eligibles Who Should Receive at Least One Initial or Periodic Screen -Make no entries on this line. This line is auto-calculated by multiplying Line 4 by Line 1b.
Note: If the number on Line 4 is greater than 1, the number 1 will be used.
(This will eliminate situations where more than one visit is expected in any age group in a year.) This
reflects the number of individuals who should receive at least one initial or periodic screen, based on
the state's periodicity schedule.

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
Line 9 -- Total Eligibles Receiving at Least One Initial or Periodic Screen -- Enter the
unduplicated number of individuals under age 21 with at least 90 days continuous enrollment within
the federal fiscal year from Line 1b, including those in fee-for-service, prospective payment,
managed care, and other payment arrangements, who received at least one documented initial or
periodic screen during the year, based on an unduplicated paid, unpaid, or denied
claim. Refer to codes in Line 6.
Line 10 -- Participant Ratio -- Make no entries on this line. This line is auto-calculated by
dividing Line 9 by Line 8. This ratio indicates the extent to which eligibles are receiving any
initial and periodic screening services during the year.
Line 11 -- Total Eligibles Referred for Corrective Treatment -- Enter the unduplicated
number of individuals from Line 1b, including those in fee-for-service, prospective payment,
managed care, and other payment arrangements, who had a paid, unpaid, or denied claim for a
visit/service that occurred within 90 days from the date of an initial or periodic screening within
the reporting period, where none of the following is included as part of the claim: capitation
payments, administrative fees, transportation services, nursing home services, ICF-MR services,
HIPP payments, inpatient services, dental care, home health services, long-term care services, or
pharmacy services. Include only those instances where both the screening and the visit/service for
which the subsequent claim was processed occurred within the reporting period.
Dental and Oral Health Lines 12a – 12g
NOTE A: For purposes of reporting the information on dental and oral health services in Lines
12a – 12g, “unduplicated” means that an individual may be counted only once on each line.
However, an individual may be counted on two or more lines. For example, individuals under the age
of 21 may be counted once on Line 12a for receiving any dental service, counted again on Line 12c
for receiving a dental treatment service and, if applicable, counted again on Line 12f for receiving an
oral health service by a qualified health care practitioner or by a dental professional who is neither a
dentist nor providing services under the supervision of a dentist. These numbers should be inclusive
of services reimbursed directly by the state under fee-for-service, or under managed care,
prospective payment, or any other payment arrangements, or through any other health or dental
plans that contract with the state to provide services to Medicaid or CHIP Medicaid expansion
enrollees, based on an unduplicated paid, unpaid, or denied claim. For each dental or oral health line
(Lines 12a – 12g), the universe of appropriate procedure codes to report is provided in the
instructions below (HCPCS or equivalent CDT or CPT codes).
NOTE B: “Dental services” refers to services provided by or under the supervision of a dentist.
Supervision is a spectrum and includes, for example, direct, indirect, general, collaborative or
public health supervision as provided in the state’s dental practice act. The most common
examples of this are dentists themselves, and dental hygienists who are working under the
supervision of dentists. “Oral health services” refers to services provided by any qualified
health care practitioner or by a dental professional who is neither a dentist nor providing services
under the supervision of a dentist. The most common examples of this are primary care medical

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
providers and dental hygienists or dental therapists who are not working under the supervision
of a dentist.
NOTE C: Each dental or oral health line, Lines 12a-12g, collects information related to a type of
dental service, a type of oral health service, or both. As described in Note B, this distinction
relates to the type of provider who delivered the service. The instructions for each dental or oral
health line specify the provider type(s) relevant to that line. It is important to pay close attention to
this part of the instructions, and to report on each line only services delivered (rendered) by the
type(s) of providers specified for that line. Rendering provider type can usually be discerned from
the claim form. For example: a child who received a fluoride varnish treatment (D1208) from a
dentist should be reported on Line 12b, preventive dental service; a child who received a fluoride
varnish treatment from a physician should be reported on Line 12f, oral health service. Both
children should be reported on Line 12g, preventive dental or oral health service.
Line 12a -- Total Eligibles Receiving Any Dental Services -- Enter the unduplicated number
of individuals under the age of 21 with at least 90 continuous days of enrollment during the federal
fiscal year from Line 1b who received at least one dental service by or under the supervision of a
dentist. These services are defined by HCPCS codes D0100 – D9999 (or equivalent CDT codes
D0100 – D9999), or equivalent CPT codes, based on an unduplicated paid, unpaid, or denied
claim. All individuals reported on Lines 12b through 12e should be reported on this line, though an
individual should be counted only once on this line regardless of how many dental services he or
she received during the reporting period. See Notes A, B, and C, above.
Line 12b -- Total Eligibles Receiving Preventive Dental Services -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during the
federal fiscal year from Line 1b who received at least one preventive dental service by or under
the supervision of a dentist. These services are defined by HCPCS codes D1000 - D1999 (or
equivalent CDT codes D1000 – D1999), or equivalent CPT codes that are for preventive dental
services and only if provided by or under the supervision of a dentist, based on an unduplicated
paid, unpaid, or denied claim. See Notes A, B, and C above.
Line 12c -- Total Eligibles Receiving Dental Treatment Services -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during
the federal fiscal year from Line 1b who received at least one dental treatment service by or
under the supervision of a dentist. These services are defined by HCPCS codes D2000 – D9999
(or equivalent CDT codes D2000 – D9999), or equivalent CPT codes that include only those that
involve periodontics, maxillofacial prosthetics, implants, oral and maxillofacial surgery,
orthodontics, adjunctive general services, and only if provided by or under the supervision of a
dentist, based on an unduplicated paid, unpaid, or denied claim. See Notes A, B, and C, above.
Line 12d -- Total Eligibles Receiving a Sealant on a Permanent Molar Tooth -- Enter the
unduplicated number of individuals with at least 90 continuous days of enrollment during the
federal fiscal year from Line 1b, in the appropriate age categories of 6-9 and 10-14, who
received a sealant on a permanent molar tooth. Sealants are defined by HCPCS code D1351 (or

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
equivalent CDT code D1351), based on an unduplicated paid, unpaid, or denied claim. For this
line, include sealants placed by any dental professional for whom placing a sealant is within his or
her scope of practice. Permanent molars are teeth numbered 2, 3, 14, 15, 18, 19, 30, 31, and
additionally, for those states that cover sealants on third molars, also known as wisdom teeth,
the teeth numbered 1, 16, 17, 32. See Notes A, B, and C, above.
Line 12e -- Total Eligibles Receiving Diagnostic Dental Services -- Enter the unduplicated
number of individuals under the age of 21 with at least 90 continuous days of enrollment during
the federal fiscal year from Line 1b who received at least one diagnostic dental service by or
under the supervision of a dentist. These services are defined by HCPCS codes D0100 – D0999
(or equivalent CDT codes D0100 – D0999), or equivalent CPT codes that are for diagnostic
dental services, and only if provided by or under the supervision of a dentist, based on an
unduplicated paid, unpaid, or denied claim. See Notes A, B, and C, above.
12f -- Total Eligibles Receiving Oral Health Services Provided by a Non-Dentist Provide r -Enter the unduplicated number of individuals under the age of 21 with at least 90 continuous days
of enrollment during the federal fiscal year from Line 1b who received at least one oral health
service by a non-dentist provider. These services are defined by HCPCS codes D0100 – D9999
(or equivalent CDT codes D0100 – D9999), or equivalent CPT codes that are for oral health
services, and only if provided by a non-dentist provider, based on an unduplicated paid, unpaid, or
denied claim. A “non-dentist provider” is any qualified health care practitioner who is neither a
dentist nor providing services under the supervision of a dentist. NOTE: Due to the variance in state
practice acts and reimbursement policies, some states may not have data to report on this line. See
Notes A, B, and C, above.
12g -- Total Eligibles Receiving any Preventive Dental or Oral Health Service -- Enter the
unduplicated number of individuals under the age of 21 with at least 90 continuous days of
enrollment during the federal fiscal year from Line 1b who received either a preventive “dental
service” by or under the supervision of a dentist or a preventive “oral health service” by a qualified
health care practitioner who is neither a dentist nor providing services under the supervision of a
dentist. These services are defined by HCPCS codes D1000 - D1999 (or equivalent CDT codes
D1000 – D1999), or equivalent CPT codes that are for preventive dental or oral health services,
based on an unduplicated paid, unpaid, or denied claim. All individuals reported on Line 12b, as well
as only those individuals from Line 12f who received preventive services, should also be reported on
this line. While some individuals may appear on both Lines 12b and 12f , an individual should be
counted only once on this line regardless of how many preventive dental services and/or
preventive oral health services he or she received during the reporting period. See Notes A, B,
and C, above.
Line 13 -- Total Eligibles Enrolled in Managed Care -- This number is reported for
informational purposes only. Enter the total unduplicated number of individuals from Line 1b who
are enrolled in any type of managed care arrangement, whether medical or dental or both, at any
time during the reporting year. This includes any capitated arrangements such as managed care
entities or individuals assigned to a primary care provider or primary care case manager,

2700.4 Instructions for Completing Form CMS-416: Annual Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) Participation Re port
Effective for the reporting period federal fiscal year 2023 (October 1, 2022 through September
30, 2023), with submission of Form CMS-416 by April 1, 2024.
regardless of whether reimbursement to the provider is fee-for-service or capitated.
Line 14a -- Total Number of Screening Blood Lead Tests -- Enter the total number of
screening blood lead tests furnished to eligible individuals under the age of six from Line 1b (that
is, with at least 90 continuous days of enrollment during the federal fiscal year) under fee-forservice, prospective payment, managed care, or any other payment arrangements, based on an
unduplicated paid, unpaid, or denied claim. Follow-up blood tests performed on individuals who
have been diagnosed with or are being treated for lead poisoning should not be counted.
You may use one of two methods, or a combination of these methods, to calculate the number of
blood lead screenings provided:
1) Count the number of times CPT code 83655 (“lead”) for a blood lead test is reported within
certain ICD-10 CM codes (see Note below); or
2) You may include data collected from use of the HEDIS®1 measure developed by the
National Committee for Quality Assurance to report blood lead screenings if your state has
elected to use this performance measure.
Line 14b -- Methodology Used to Calculate the Total Number of Blood Lead Tests -Identify the methodology used by your state to calculate the number of blood lead tests furnished
to the children reported on Line 14a by entering an “X” on the form next to the methodology
used:
1) CPT Code 83655 within certain diagnoses codes (Method I)
2) HEDIS (Method II)
3) Combination Methodology (Method III)
1

Health Effectiveness Data and Information Set

NOTE: On a claim, CPT code 83655 is the procedure code for blood lead level tests. States should
report instances of CPT code 83655 which are accompanied by a diagnosis code that would indicate
a person is receiving a screening blood lead test, such as a well-child check (for example Z00.121 or
Z00.129), exposure to lead (Z77.011), or encounter for screening for disorder due to exposure to
contaminants (Z13.88), with or without secondary codes. CPT 83655, when accompanied by a
diagnosis code of T56.0X1A–4A, T56.0X1D-4D, T56.0X1S-4S or a code in the M1A.1 series would
generally indicate that the person receiving the blood lead test had already been diagnosed with, or
was being treated for, lead poisoning. This would not be considered a screening test. States should
not report CPT codes 83655 when accompanied by a diagnosis code of T56.0X1A–4A, T56.0X1D4D, T56.0X1S-4S or a code in the M1A.1 series.