Skip to main content
HealthPartners

Coverage criteria policies

Early intensive developmental and behavioral intervention (EIDBI) - Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization is required for these specific EIDBI services:

  1. Comprehensive Multidisciplinary Evaluation (CMDE) (after the first within the calendar year)
  2. Individual Treatment Plan (ITP) Development & Monitoring (after the first within the calendar year)
  3. EIDBI Intervention – Individual or Group
  4. Coordinated Care Conference (beyond the one allotted per year)
  5. Intervention, Observation & Direction
  6. Family/Caregiver Training & Counseling – Individual or Group
  7. Travel time for provider
  8. A 60-day temporary increase of EIDBI intervention services

Coverage

  • EIDBI is generally covered subject to the indications listed below and per your plan documents.
  • EIDBI is covered when provided by a qualified EIDBI provider and supervised by a qualified supervising professional (QSP) that are enrolled with DHS and are contracted and in-network for your plan.
  • EIDBI covers activities and services that are for the direct benefit of a child
  • Early Intensive Developmental and Behavioral Intervention (EIDBI) services that are targeted to develop, enhance, and maintain the person’s developmental skills in order to improve his or her behavioral challenges and self-regulation, cognition, functional communication, learning and play, needed level of support, safety, self-care and social or interpersonal interaction.
  • EIDBI service that address the person’s medically necessary treatment goals
  • EIDBI services that meet DHS billing requirements.

Indications that are covered

EIDBI may be covered when the following eligibility and medical necessity criteria are met:

To receive services, a child must meet 1 through 6:

  1. Has a diagnosis of autism spectrum disorder (F84.0) or a related condition such as Fetal Alcohol Syndrome or Rhett’s Syndrome or meets the definition for a related condition (See definition):
    If the person is under age five, he or she may not have an ASD or related condition diagnosis but still meets medical necessity criteria. For more information, see exception to diagnostic criteria on EIDBI – Eligibility for EIDBI services.
  2. Has had a comprehensive multi-disciplinary evaluation (CMDE) that establishes his or her medical need for EIDBI services
  3. Is enrolled in Medical Assistance (MA) or MinnesotaCare
  4. Is medically stable and does not require 24-hour medical monitoring or procedures
  5. Is under age 21
  6. Meets the criteria for medically necessary EIDBI services

To receive services, a child must meet (1 through 6):

  1. The person’s symptoms are present in the early developmental period, or the symptoms either:
    1. May not have fully manifested until social demands exceeded limited capacities
    2. Were masked by learned strategies in later life.
  2. The person’s behaviors persist in frequency, intensity and duration across environments.
  3. The person’s behaviors also either:
    1. Present a health or safety risk to self or others
    2. Cause clinically significant impairment in his or her functional participation in the home or community such that typical family and community activities are regularly disrupted or unmanageable.
  4. Based on the CMDE, the person requires 10 or more hours a week of EIDBI services.
  5. Less intensive treatment options for the person have been considered.
  6. The CMDE provider determines that the interventions covered by EIDBI services will appropriately target the core deficits of the person with a diagnosis of ASD or a related condition.

Under age five

If the person is under age five, he or she may not have an ASD or related condition diagnosis but still meets medical necessity criteria. The diagnosing provider may choose not to use the current DSM criteria only if the person is under age 5 and has risk factors for ASD, such as:

  1. Prematurity
  2. Siblings diagnosed with ASD or other familial/genetic risk
  3. Presence of associated intellectual disability and language impairment
  4. Signs of ASD’s core deficits but not yet diagnosed.

Medical necessity treatment guidelines

Provide a framework for recommendations for treatment intensity and frequency based on age, ASD core deficits, developmental needs, domains impact scores and the individual needs of the child and family.

The treatment recommendation should be at least 10 hours of EIDBI services per week. For a person over age seven, the treatment recommendation should not exceed 20 hours of EIDBI services per week

For school-aged children over 7 years of age, medical necessity determination must consider time spent in school and must not exceed 20 hours per week unless the child meets the exceptions to the medical necessity determination guidelines.

If the proposed EIDBI treatment plan include or replace academic goals and objectives that otherwise are provided through the child’s individual education plan or individual family service plan as required under the Individual with Disabilities Education Improvement Act of 2004, it will be denied.

    Age

    Hours

    None to

    Minimal Impact
    Score 0-6

    Mild Impact
    Score 7-14

    Moderate

    Impact
    Score 15-22

    Severe Impact
    Score 23-30

    0-35
    Months

    10-40
    hours

    0

    10

    25

    40

    36 Months
    to 5 years

    10-40
    hours

    0

    10

    25

    40

    5-7 years

    10-40
    hours

    0

    10

    25

    40

    7-11 years

    10-20
    hours

    0

    10

    15

    20

    12-18 years

    10-20
    hours

    0

    10

    15

    20

    19-21 years

    10-20
    hours

    0

    10

    15

    20

Exceptions to Recommended EIDBI Treatment Guidelines

Less than 10 hours

May approve less than 10 hours of EIDBI services per week if one or more of the following are true:

  1. Person is under age three.
  2. Parent/primary caregiver requests fewer hours.
  3. CMDE provider recommends less than 10 hours of EIDBI services per week and documents rationale in the CMDE, DHS-7108.
  4. The ITP, DHS-7109 documents other services the person receives which indicate a need for less than 10 hours of EDIBI services per week.

More than 20 hours for a person older than age seven

May approve more than 20 hours of EIDBI services per week for a person older than age seven if at least one of the following are true:

  1. Person needs crisis intervention.
  2. Person is at risk of out-of-home placement due to challenging behaviors.
  3. Person needs an intensive boost of intervention for a short period of time based on a developmental or environmental transition or change in circumstances.
  4. Person did not have access to EIDBI services early in life.
  5. CMDE provider recommends more than the 20 hours of EIDBI services per week and documents rationale in the CMDE, DHS-7108.

Continued Care - Reauthorization of EIDBI services

All of the following criteria must be met before EIDBI services are reauthorized:

  1. The person continues to meet medical necessity criteria for EIDBI services, as documented in the CMDE.
  2. The ITP documents:
    1. Measureable progress on developmentally appropriate goals and objectives that are increasingly generalized across environments and people
    2. Any changes or updates to the parent/primary caregiver’s input into the goals/objectives and progress monitoring updates
    3. Any changes or updates to the parent/primary caregiver’s preference for participation in treatment and family/caregiver training and counseling.
    4. The qualified supervising professional (QSP) determines that the person will continue to benefit from the prescribed EIDBI services based on documented progress.
  3. The progress on overall goals documented in the ITP, DHS-7109 indicates that reasonable progress is expected to continue.
  4. The parent or legal guardian signs the ITP, DHS-7109, documenting his or her continued agreement with and consent for EIDBI services.

Request for Change in EIDBI Intensity Criteria

A change in the intensity level of EIDBI services (increase or decrease) may be determined medically necessary for one or more of the following reasons:

  1. Person starts school.
  2. Person transitions from EIDBI to other services.
  3. Significant change in the family.
  4. Increase or decrease in other related services.
  5. CMDE provider or QSP recommends a change in the intensity level of EIDBI services and documents rationale.
  6. Parent or legal representative requests a change in the intensity level of EIDBI services and the CMDE provider or QSP documents supportive rationale.
  7. Person received the recommended treatment amount and did not make progress.

Telemedicine

Telemedicine services and consultations must be provided with the same service thresholds, authorization requirements and reimbursement rates as services delivered face-to-face.

If they are enrolled with MHCP as EIDBI providers, the following provider types can deliver and bill for EIDBI telemedicine services: Physician, Nurse practitioner, Clinical psychologist. Clinical social worker, Speech therapist, Physical therapist or Occupational therapist.

A comprehensive multi-disciplinary evaluation (CMDE) provider, qualified supervising professional (QSP), Level I or Level II EIDBI provider may apply to provide EIDBI services via telemedicine if they meet the qualifications and complete the Telemedicine Assurance statement.

Delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site.

Two-way, interactive video can be used to provide the following services if medically appropriate to the condition and needs of the child. Services include:

  1. Comprehensive multi-disciplinary evaluation (CMDE)
  2. Coordinated care conference
  3. Family/caregiver training and counseling
  4. Intervention observation and direction.

Services must be physically face-to-face or virtually face-to-face via the interactive video. Either the child or family must be present or the interactive systems must comply with HIPAA privacy, security requirements and regulations.

Travel Time

Providers may bill travel time to and from the child's home to provide covered benefit intervention, family/caregiver training and counseling and intervention observation and direction

Termination of EIDBI services

Termination of EIDBI services may be determined medically necessary for one or more of the following reasons:

  1. The person has achieved maximum benefit from EIDBI services, as documented by measurable progress on and generalization of goals and objectives across environments and people.
  2. The person no longer meets medical necessity criteria for EIDBI services.
  3. EIDBI services make the person’s symptoms persistently worse.
  4. The person is not making progress toward individual treatment goals. This lack of progress is demonstrated by the absence of any documented, sustainable, generalized and measurable progress.
  5. The person has not shown signs of or the provider does not reasonably expect the person to show signs of measurable progress within 12 months of the initial ITP development. This is demonstrated by both:
    1. Lack of documented progress during the ITP update
    2. Adjustments to the treatment plan that haven’t benefited the person.
  6. The parent/ or legal guardian requests termination of services.
  7. The CMDE provider or QSP recommends a termination of services because the person would likely benefit from another service or be more appropriately served by less-intensive forms of treatment.

Re-starting EIDBI services after termination

To re-start EIDBI services after a person’s EIDBI services were terminated, the EIDBI provider should provide a rationale for why EIDBI services are now recommended.

If the person’s CMDE is more than 12 months old, the person must receive a new CMDE, ITP and meet the medical necessity criteria to re-start EIDBI services.

Indications that are not covered

The EIDBI Benefit does not cover services that are:

  1. Conducted over the telephone, or via mail or email
  2. For the purpose of reporting, charting or record keeping (except when this is integral to a covered CMDE or ITP service)
  3. Not documented in the person’s health service record or ITP in the manner outlined by this policy manual or Minn. R. Part 9505.2175
  4. Primarily custodial, day care or respite
  5. Primarily recreational and not supervised by a medical professional, e.g., sports activities, craft activities, meal/snack time, trips to community activities tours, etc. (These activities may be covered if they are primarily for treatment and provided according to the person’s ITP.)
  6. The responsibility of a residential or program license holder (e.g., foster care providers) according to a service agreement or administrative licensing rules.
  7. Have not been approved by the state’s medical review agent (except for services that do not require authorization)
  8. Include or replace academic goals that are otherwise included in the person’s Individual Education Plan (IEP) or Individual Family Service Plan (FSP), as required under the Individual with Disabilities Education Improvement Act of 2004.
  9. Provided by a parent, legal guardian or another person legally responsible for the person
  10. Provided by a person who does not meet the provider qualifications
  11. In violation of Medical Assistance (MA) policy as outlined in Minn. R, 9505.0220
  12. Provided to the general community (e.g., prevention and education programs)
  13. When the person is sleeping or napping
  14. Without the required supervision.
  15. The EIDBI Benefit also does not cover services that are not provided (e.g., appointment no-shows) or not provided directly to a person who is present, either physically or via interactive video. Exception: The following services do not require the person to be present:
    1. Coordinated care conference
    2. Family/caregiver training and counseling
    3. ITP development.
  16. Provider training activities that do not meet the criteria for observation and direction
  17. Transportation for the person
  18. Intervention services delivered to one person by two or more EIDBI providers (of any level) at the same time.

Definitions

Autism spectrum disorder (ASD)

Core symptoms of ASD include:

  1. Persistent deficits in verbal and nonverbal communication
  2. Persistent deficits in social interaction and relationships across multiple contexts
  3. Restricted, repetitive patterns of behavior, interests or activities.

A person’s symptoms may range in severity.

Additional diagnostic criteria include the following:

  1. Symptoms must be present in the person’s early developmental period
  2. Symptoms cause clinically significant impairment in social, occupational or other important area of current functioning
  3. These disturbances are not better explained by intellectual disability or global developmental delay. (Note: A person may have an intellectual disability and ASD that co-exist.)

For a full definition of ASD, see the current version of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM).

Comprehensive multi-disciplinary evaluation (CMDE)

Information and assessments from parents, caregivers, medical, educational and mental health services used to determine medical necessity for this benefit, identify treatment and services recommendations and guide development of the treatment plan. CMDE must be completed annually within 60 to 30 days before the end date of the current services authorization and is valid for 12 months unless there is a significant change in condition. A new CMDE is not required when the child and family choose a different provider or enroll / disenroll from a managed care plan. Up to two providers can bill for the CMDE for the same recipient for up to 5 visits to be completed within 30 days.

The list of CMDE providers can be found here: http://mhcpproviderdirectory.dhs.state.mn.us/SearchResults.aspx

Coordinated Care Conference

Providers eligible to bill for a coordinated care conference include the CMDE provider, the Qualified Supervising professional or a Level l or ll provider.

The coordinated care conference consists of a team of professionals that work with the child and family to develop and coordinate the implementation of the individual treatment plan (ITP) and integrate services across providers and service delivery systems. It must include the child or parents and a Qualified Supervising Professional. The coordinated care conference is optional based on parent request only. The care conference is conducted once per year and in conjunction with initial and annual ITP development and reviews the results of the CMDE, progress monitoring and other service updates. It includes:

  • Coordinate and integrate information from the CMDE process
  • Recommend intensive treatment scope, modality, intensity, frequency and duration and document in the individual treatment plan
  • Review the child’s progress toward goals with the child’s family
  • Coordinate services provided to the child and family
  • Identify the level and type of parent involvement in the child’s intensive treatment
  • Integrate care and services across service providers to ensure access to appropriate and necessary care including medically necessary speech therapy, occupational therapy, mental health, human services or special education
  • Make referrals to other services when needed

Early Intensive Developmental and Behavioral Intervention (EIDBI)

Early Intensive Developmental and Behavioral Intervention (EIDBI) services offer medically necessary treatment to children under the age of 21 years old on Medical Assistance (MA) with autism spectrum disorder (ASD) or related conditions. EIDBI provides a range of individualized, intensive, developmental and behavioral interventions that target the functional skills and core deficits of ASD and related conditions. EIDBI promotes optimal child independence and participation in family, school and community life. EIDBI services educate and support families, reduce stress, and improve long-term outcomes and quality of life for children and their families. DHS treatment modalities approved as covered services includes: Applied Behavioral Analysis (ABA), Developmental Individual-difference Relationship-based model (DIR®/Floortime), Early Start Denver Model (ESDM), P.L.A.Y Project and Relationship Development Intervention (RDI)

Emotional disturbance

Defined in Minn. Stat. §245.4871, subd. 15.

Family/caregiver training and counseling:

Specialized training and education a family or primary caregiver receives to help with their child's needs and development. Family caregiver training and counseling helps family and caregivers: increase family resilience, learn how to access supports, understand available resources, and understand their child’s condition. Services must be culturally and linguistically appropriate and meaningful to the child and family. It includes direct hands-on demonstration/modeling of effective strategies to support the child’s development, reflection, feedback and support, services that improve parent-identified quality of life issues for child, parent and family and video modeling and review.

Mental illness

Defined in Minn. Stat. §245.462, subd. 20

Mental illness does not include autism or other pervasive developmental disorders.

Related Condition

A related condition is a condition that is closely related to ASD and:

  1. Is severe and chronic
  2. Results in impairment of a person’s adaptive behavior and function similar to that of a person with ASD
  3. Requires treatment or services similar to those required for a person with ASD
  4. Results in a person’s substantial functional limitations in three core developmental deficits of ASD: (a) social interaction, (b) non-verbal/social communication, (c) restrictive, repetitive behaviors or hyperreactivity or hyperactivity to sensory input
  5. May include deficits in one or more of the following related developmental domains: (a) behavioral challenges, (b) cognitive functioning, (c) expressive communication, (d) receptive communication, (e) safety, (f) self-care, and (e) sensory processing, and (f) self-regulation
  6. Is not attributable to mental illness as defined in Minn. Stat. §245.462, subd. 20, or an emotional disturbance as defined in Minn. Stat. §245.4871, subd. 15.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization per indication listed under Administrative Process:

    Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit

    Code

    Modifier

    Unit

    Comprehensive multi-disciplinary evaluation

    0359T

    UB, AM, TG, HP, HO, GT

    1 DAY

    Individual Treatment Plan (ITP) Development & Monitoring - Autism service plan development

    H0032

    UB, HK, HP, HO, HN, UD

    15 MINS

    Coordinated Care Conference

    T1024

    UB, AM, TG, HP, HO, HK, HN, GT

    1 DAY

    EIDBI Intervention - Individual  

    0368T, 0369T
    0364T, 0365T

    UB, HP, HO, HK, HN, HM, TF

    30 MINS

    EIDBI Intervention - Group - Social Skills Group

    0366T, 0367T

    UB, HP, HO, HK, HN, HM, TF

    30 MINS

    Intervention Observation & Direction

    0362T, 0363T

    UB, HP, HO, HK, HN, GT

    30 MINS

    Family/Caregiver Training & Counseling - Individual

    T1027

    UB, HP, HO, HK, HN, GT

    15 MINS

    Family/Caregiver Training & Counseling - Group

    T1027

    UB, HP, HO, HK, HN, HQ

    15 MINS

    Travel Time

    H0046

    UB

    1 MILE

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minnesota Department of Human Services Provider Manual –Early Intensive Developmental and Behavioral Intervention -Revision 10/20/17
  2. Minnesota Department of Human Services – Early Intensive Developmental and Behavioral Intervention Benefit Policy Manual (accessed 12.14.2017)
  3. Legal Authority – Minnesota State Statute 256B.0949
  4. Approved Medicaid State Plan Amendment TN 14-08

Go to

Policy activity

  • 08/16/2016 - Date of origin
  • 01/01/2018 - Effective date
Review date
  • 01/2018
Revision date
  • 12/27/2017

Related content