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Minnesota Department of Human Services Early Intensive Development and Behavioral Intervention Manual
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How to complete CMDE Medical Necessity Summary Information, DHS-7108

For more information about the EIDBI service, see EIDBI – Comprehensive multi-disciplinary evaluation (CMDE).

Page posted: 2/17/17

Page reviewed: 11/14/17

Page updated: 11/14/17

Legal authority

CMS-approved EIDBI state plan amendment (PDF), Minn. Stat. §256B.0949

Definition

Comprehensive multi-disciplinary evaluation (CMDE): An EIDBI service that covers the required comprehensive evaluation of the person.

CMDE Medical Necessity Summary Information, DHS-7108: The form the CMDE provider must use to document the results of the person’s evaluation. He or she must submit DHS-7108 to the state medical review agent for medical-necessity approval before the person can receive or renew EIDBI services.

Instructions

This page provides guidance to CMDE providers on how to complete CMDE Medical Necessity Summary Information, DHS-7108.

Providers must:

  • • Always open a new form when starting a new authorization request to ensure you are using the latest version (never print or save the online forms)
  • • Complete all required fields
  • • Submit the form to DHS when completed
  • Save the form as a PDF and submit to KEPRO for authorization (see MHCP EIDBI Provider Manual – Service Authorization).
  • Type of CMDE

    In this section, indicate which type:

  • • Initial: The first CMDE for that person.
  • • Annual: Yearly update for the CMDE
  • • Correction: If a correction is necessary to the previous submission.
  • Section A: Child’s personal information

    In section A, document:

  • • Person’s information (e.g., parent/primary caregiver(s), date of birth, gender, address, living situation, insurance, race/ethnicity, etc.)
  • • Whether you used an interpreter.
  • If an interpreter participates, he or she must sign Addendum B, DHS-7108A.

    Section B: CMDE referral and diagnostic information

    In section B, document:

  • • When and why the person was referred for a CMDE
  • • Who referred the person and his or her information
  • • The CMDE provider(s) information (e.g., name, National Provider Identifier (NPI) number, agency, etc.)
  • • The person’s primary care physician/medical provider and his or her contact information
  • • A summary of the person’s previous diagnostic information and clinical findings.
  • Additional notes

    Follow additional instructions to complete the diagnostic information and summary of clinical findings subsections:

  • • List ASD and non-ASD diagnoses (as applicable) to coordinate other services and for research purposes
  • • Determine if the person needs a Diagnostic Assessment (DA) to access non-EIDBI services (a CMDE is not the same as a DA)
  • • List diagnostic code(s) using the current International Classification of Diseases (ICD) code(s)
  • • Document if you used the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Childhood (DC: 0-3R or DC: 0-5R)
  • • Make sure the provider who completed the assessment(s) signed Addendum B, DHS-7108
  • • Complete an assessment and determine a diagnosis if the person does not have a previous diagnosis.
  • For diagnostic criteria and information about assessment tools, see EIDBI – Eligibility for EIDBI services.

    Section C: EIDBI treatment recommendations

    Medical necessity

    Your treatment recommendations must be based on medical necessity. For guidelines, see the “medical necessity treatment guidelines” section on EIDBI – Medical necessity criteria.

    Parent/primary caregiver

    In section C, document:

  • • Parent/primary caregiver’s preference for training and counseling
  • • Your recommendation for family/primary caregiver training and counseling.
  • Your recommendation must include:

  • • Range of service intensity (must include a minimum and maximum number of hours)
  • • Setting(s) in which the parent/primary caregiver should receive training and counseling.
  • Person

    Document your recommendation for intervention services. Your recommendation must include:

  • • Weekly or monthly range of service intensity that you assess as clinically necessary for the person to progress (must include a minimum and maximum number of hours)
  • • Whether the person should receive intervention services individually and/or in a group
  • • Setting(s) in which the person should receive intervention services.
  • For a complete listing and description of settings in which a person may receive EIDBI services, see EIDBI – Settings.

    Exceptions to medical necessity treatment guidelines

    If you want to request an exception to the medical necessity treatment guidelines (PDF), you must provide clear rationale and supporting documentation. This could include information from other qualified professionals who work with the person and family.

    See the “medical necessity treatment guidelines” section on EIDBI – Medical necessity criteria.

    Progress monitoring frequency

    Document how often you recommend the treating provider(s) monitors the person’s progress. If you recommend monitoring progress less frequently than every six months, you must provide clear rationale.

    Section D: Medical and developmental history

    In section D, describe the:

  • • Person’s symptoms, including the age symptoms were first noticed and who noticed them
  • • Family’s primary concerns/areas with which they need help
  • • Person’s medical history, obtained from the person’s primary physician/medical provider.
  • When describing the person’s medical history, include:

  • • Prior medical evaluations
  • • All medications, allergies and hospitalizations, if applicable
  • • Developmental history, including pregnancy/delivery, developmental milestones and any other significant events
  • • Relevant developmental concerns and other conditions of family members (other conditions may include behavioral, mental health, etc.)
  • • Strengths of the person and family.
  • Section E: Structured observation

    As part of the CMDE process, you must complete a structured observation of the person. The structured observation must:

  • • Be conducted face-to-face or via telemedicine by an MHCP-enrolled CMDE provider
  • • Be completed within the allotted timeframe for the CMDE evaluation
  • • Describe the person’s core functional deficits.
  • In section E, document:

  • • Observation results and summary
  • • Date and setting the observation occurred
  • • Who completed the observation
  • • Duration of the observation.
  • DHS recommends you complete a second observation in a second setting. If another observation is completed, document it in the CMDE. The second observation may be done by a provider that is not enrolled as an EIDBI or MHCP provider (e.g., teacher, speech therapist, etc.).

    Section F: Summary results for ASD or related conditions core deficits

    In section F, document the person’s degree of deficits in the following developmental domains:

  • • Social interaction
  • • Social communication (include if this is with or without accompanying intellectual impairment)
  • • Restrictive, repetitive behaviors and/or sensory regulation (include if this is with or without accompanying intellectual impairment)
  • • Self-care skills
  • • Challenging behaviors
  • • Expressive communication
  • • Receptive communication
  • • Cognitive functioning
  • • Safety needs
  • • Overall level of support needed.
  • Score each developmental domain based on information from:

  • • Additional reports
  • • Clinical judgement
  • • Formal and informal assessment tools
  • • Medical and developmental history
  • • Observations
  • • Parent/primary caregiver interviews.
  • The CMDE provider uses these summary results (or “impact scores”) to recommend medically necessary treatment. For more information, see EIDBI – Medical necessity criteria.

    Section G: Parent/primary caregiver interview

    As part of the CMDE process, you must interview at least one of the person’s parent(s)/primary caregiver(s).

    Based on the interview and clinical judgement, score each of the parent/primary caregiver domains:

  • • Confidence
  • • Level of stress
  • • Perception of quality of life.
  • The interview must be completed by the CMDE provider, QSP or another EIDBI provider with an NPI number.

    Section H: Summary of referrals

    In section H, document:

  • • Referrals you make for other services
  • • Rationale for referrals
  • • Coordination of services the person currently receives.
  • Addendum A

    In Addendum A, which is part of DHS-7108 form, document:

  • • If the person meets DSM-V criteria (for more information, see EIDBI – Eligibility for EIDBI services)
  • • Level of support needed for “social communication” and “restrictive, repetitive behaviors, sensory regulation” based on the summary results for ASD or related conditions core deficits. Include if the person has an accompanying intellectual or language impairment
  • • Results of any ASD, IQ/developmental or other assessment tools used.
  • Addendum B

    Once DHS-7108 is completed, the CMDE provider(s), parent/legal representative(s) and the interpreter (if applicable), must sign EIDBI Comprehensive Multi-Disciplinary Evaluation (CMDE) Medical Necessity Summary Information Signature Form (Addendum B), DHS-7108A (PDF).

    The date the parent/ legal representative(s) signs the CMDE is the date the evaluation is considered complete.

    Additional resources

    CMDE Medical Necessity Summary Information, DHS-7108
    EIDBI – Comprehensive multi-disciplinary evaluation (CMDE)

    EIDBI – Eligibility for EIDBI services

    EIDBI – Medical necessity criteria

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