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Extension of deadline to submit EPSDT Provider Agreement

Effective Nov. 1, 2015, the Mississippi Division of Medicaid (DOM) received Centers for Medicare and Medicaid Services approval of State Plan Amendment (SPA) 15-017 Early and Periodic Screening, Diagnosis and Treatment (EPSDT). SPA 15-017 requires DOM EPDST providers to adhere to the American Academy of Pediatrics Bright Futures periodicity schedule for physical, mental, psychosocial and/or behavioral health, vision, hearing, adolescent, and developmental screening services.

EPSDT screening providers, currently enrolled in the program, must update their enrollment status by completing the EPSDT Provider Agreement. The EPSDT Provider Agreement is located on the DOM website on the Forms webpage.

Providers must mail or fax the completed and signed EPSDT Provider Agreement by Nov. 30, 2016.

Mailing address:
Division of Medicaid – Office of Medical Services
550 High Street, Suite 1000
Jackson, MS 39202

Fax: 601-359-6147

Failure to send the completed and signed EPSDT Provider Agreement during the extension time frame of Nov. 1-30, 2016 may result in provider disenrollment from the EPSDT program.

Instructions for completing the EPSDT Provider Agreement:

  • All requested information on the agreement must be provided.
  • Incomplete agreements will not be processed.
  • The provider must sign and date the form.

For more information visit the EPSDT webpage. If you have any questions or need additional assistance, please contact the Office of Medical Services by phone at 601-359-6150.