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Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit

Revised: 03-13-2017

Overview

Early Intensive Developmental and Behavioral Intervention (EIDBI) services offer medically necessary treatment to people under the age of 21 on Medical Assistance (MA) with autism spectrum disorder (ASD) and related conditions.

The purpose of the EIDBI benefit is to provide medically necessary early intensive intervention that targets the functional skills and core deficits of people with ASD and related conditions. As well as:

  • • Educate, train and support their parents and families
  • • Promote people’s independence and participation in family, school and community life
  • • Improve long-term outcomes and the quality of life for people and their families
  • This page covers the following information:

  • Eligible Providers
  • Eligible People
  • Covered Services
  • Noncovered Services
  • Service Authorization
  • Billing
  • Managed Care Organizations
  • Special Needs BasicCare
  • Definitions
  • Legal References
  • Additional Resources
  • For more information about the EIDBI benefit, see the EIDBI Benefit Policy manual.

    Eligible Providers

    In order to provide, bill and receive payment for EIDBI services, a provider must:

  • • Be enrolled as a Minnesota Health Care Programs (MHCP) provider
  • • Meet all provider qualifications on the EIDBI assurance statement for the provider type
  • • Have a DHS-approved service authorization (SA) to provide services for the person
  • Refer to the Overview of EIDBI providers page in the EIDBI Benefit Policy manual for more information.

    Provider Enrollment

    To enroll as an EIDBI provider, follow the instructions on the Early Intensive Developmental Behavioral Intervention (EIDBI) Provider Enrollment page. All MHCP providers must register a MN–ITS account.

    Eligible People

  • A person is eligible to receive EIDBI services if he or she meets all of the following criteria:
  • • Has been diagnosed with autism spectrum disorder (ASD) or a related condition
  • • Has had a comprehensive multi-disciplinary evaluation (CMDE) that establishes his or her medical need for EIDBI services
  • • Is enrolled in Medical Assistance (MA) or MinnesotaCare
  • • Is medically stable and does not require 24-hour medical monitoring or procedures
  • • Is under age 21
  • Refer to the Eligibility for EIDBI services page in the EIDBI Benefit Policy manual for more information.

    Covered Services

    The EIDBI benefit covers the following services:

  • Comprehensive multi-disciplinary evaluation (CMDE)
  • Individual treatment plan (ITP) development and progress monitoring
  • Coordinated care conference
  • Intervention – group and individual
  • Intervention observation and direction
  • Family or caregiver training and counseling
  • Travel time
  • Only eligible provider types may perform each service. Telemedicine is an option for some EIDBI services. Refer to the EIDBI services page in the EIDBI Benefit Policy manual for more information.

    Non-covered Services

    For a list of non-covered services, refer to the EIDBI services page in the EIDBI Benefit Policy manual.

    Access Services

    EIDBI does not cover transportation and language interpreter services. As a Minnesota Health Care Program provider, it may be covered through access services. Refer to the MHCP Provider Manual’s Access Services section for more information.

    Service Authorization

    Some EIDBI services require service authorization (SA). The authorization requirement safeguards against inappropriate and unnecessary use of health care services under state and federal law.

    The SA allows qualified providers to bill and receive payment from MHCP after providing EIDBI services. However, having an approved SA does not guarantee MHCP payment. The provider must meet all other MHCP requirements to receive payment.

    Services that Require Authorization

    The following services require authorization prior to service delivery:

  • • Family or caregiver training and counseling
  • • Intervention – individual and group
  • • 60-day temporary increase of EIDBI intervention services – DHS-7109D (PDF)
  • • Intervention observation and direction
  • • ITP progress monitoring (ongoing)
  • • Travel time
  • Services that Do Not Require Authorization

    The following services do not require authorization prior to service delivery:

  • • The initial ITP
  • • The annual CMDE
  • • One coordinated care conference per year
  • Process

    Information in this section pertains to fee-for-service MHCP recipients only. If the person is enrolled in a prepaid health plan, contact the appropriate managed care organization for authorization requirements. When people have private insurance, follow the primary insurance’s authorization procedures and other applicable rules.

    MHCP’s current medical review agent is Keystone Peer Review Organization (KEPRO). MHCP contracts with KEPRO to process EIDBI service authorization requests.

    Note the following timelines in the EIDBI service authorization process:

  • • EIDBI service authorizations must end on the last day of a month.
  • • Each EIDBI service authorization request cannot exceed a six-month time span.
  • • A person must receive his or her annual CMDE at least 30 but no more than 60 calendar days before the end date of the current service authorization period.
  • • The CMDE must be completed prior to the ITP. (This means the CMDE and ITP cannot be signed on the same day and the ITP cannot be signed prior to the CMDE.)
  • • The QSP and parent or legal representative may sign the ITP on the same day. The ITP will not be accepted if the date of the QSP’s signature is prior to the date of the legal representative’s signature.
  • Responsibilities

    The CMDE provider is responsible to:

  • • Submit the completed CMDE DHS-7108 (PDF), including the CMDE signature page, to the web-based KEPRO Atrezzo portal
  • • Ensure that all documentation in the CMDE is complete and accurate prior to submission
  • The QSP provider is responsible to:
  • • Receive medical necessity approval before submitting the ITP
  • • Submit the completed ITP DHS-7109 (PDF), including the ITP signature page and the completed "week in the life" page, to the web-based KEPRO Atrezzo portal
  • • Submit a denial letter or explanation of benefits from the primary insurer if MA is secondary
  • • Ensure that all documentation is complete and accurate prior to submission
  • In general, the EIDBI provider agency is responsible to:

  • • Use the Atrezzo portal to submit information to and communicate with KEPRO. KEPRO will not accept documentation sent via fax or mail, and the MN-ITS message screen has limited space.
  • • Providers must reference the KEPRO Atrezzo portal to check the status of the CMDE. Since the annual CMDE does not require authorization, a SA is not created and a notification will not be sent via MN-ITS.
  • KEPRO will do the following within five business days of receiving the CMDE:

  • • Verify that all the required components of the CMDE are present
  • • Pend the case and notify providers through the Atrezzo message inbox if additional information is needed
  • • Review the documentation and make a medical necessity determination
  • KEPRO will do the following within ten business days of receiving the ITP:

  • • Enter information from the ITP and CMDE into Medicaid Management Information System (MMIS)
  • • Verify all required components of the ITP are present
  • • Pend the case and notify providers through the Atrezzo message inbox if additional information is needed
  • • Complete an integrated review process of the CMDE, ITP and other MHCP-covered services the person receives in order to determine authorization for EIDBI services
  • If KEPRO pends the case in the Atrezzo portal and requests additional information:

  • • The provider has 20 business days to upload the requested information or make the requested corrections. The provider must submit all the additional information requested at one time to KEPRO.
  • • KEPRO has three business days from when it receives the additional information to review and make an approval or denial determination.
  • DHS will send letter notifications to the provider:

  • • 60 days prior to the annual renewal date for the CMDE
  • • 60 days prior to the six month renewal date for the ITP
  • Request Changes to Approved Service Agreement

    The provider may request:

  • • An adjustment to an existing, approved service agreement (i.e., “technical change”)
  • • A temporary increase in EIDBI intervention services above what was recommended in the person’s CMDE or ITP
  • Technical Change Request

    To request a technical change, complete and submit EIDBI Technical Change Request, DHS-6516 (PDF). See DHS-6515A (PDF) for:

  • • Instructions on how to complete and submit the technical change request form, DHS-6516
  • • Examples of and limitations on how and when to use the form
  • 60-Day Temporary Increase in Intervention Services

    To request a 60-day temporary increase in intervention services, complete and submit EIDBI 60-Day Temporary Increase Request for Intervention Services, DHS-7109D (PDF). For instructions on how to complete and submit the form, see DHS-7109E (PDF). Within 10 business days of receiving the form, KEPRO will make an authorization determination.

    Resources

    Contact the KEPRO provider call center at 866-433-3658 or 612-354-5589 for:

  • • Login credentials
  • • Portal access
  • • Questions regarding the current status of submitted cases
  • • Submit additional documentation on an existing case
  • • Training on how to create a new case
  • Refer to the KEPRO website and the MHCP Provider manual Authorization section for more information.

    Billing

    Refer to the EIDBI Billing Grid for:

  • • Service names
  • • Procedure codes
  • • Reimbursement percentage rates
  • • Modifiers
  • • Provider limits and requirements
  • • Units
  • • Service limits
  • Refer to the MHCP Fee Schedule for the most current rate information.

    Submitting Claims

    To submit claims for EIDBI services:

  • • Use MN−ITS direct data entry (DDE) or your own X12 compliance software (batch billing system)
  • • Use the professional (837P) claim
  • • Follow the instructions in MN–ITS User Manual Guide – EIDBI Claims
  • A claim submission must include:
  • • The pay-to provider
  • • The procedure code for the EIDBI service provided
  • • The appropriate modifier(s)
  • • The UMPI or NPI of the rendering provider who delivered the service (see note below for exception)
  • • The supervising provider for any services that require the supervision of a QSP
  • Note: Claims for any services delivered by a Level III provider submitted prior to Jan. 1, 2018, do not require the UMPI number of the rendering provider.

    When submitting claims for EIDBI services:

  • • Bill only for EIDBI services already provided
  • • Bill only for services approved on the SA
  • • Do not bill services that require an SA on the same claim as services that do not require an SA
  • • Submit your usual and customary charges for the service
  • • Use the most current and specific diagnosis codes
  • • Use date spans only when you have provided services for all dates in the span
  • • Only bill codes for “the first 30 minutes” one time per day, per code
  • • Use place of service (POS) 12 (home) for EIDBI services provided in a community setting, as outlined in the person’s ITP
  • Tribal providers should refer to the Tribal and Federal Indian Health Services page in the MHCP Provider manual for more information.

    Telemedicine via Interactive Video
    Use telemedicine billing for eligible EIDBI telemedicine services. Services provided using telemedicine have the same service thresholds, reimbursement rates and authorization requirements as services delivered face-to-face. Bill for services delivered via telemedicine with the modifier “GT.” MHCP does not reimburse for connection charges, or origination, set-up or site fees.

    Refer to EIDBI telemedicine services page in the EIDBI Benefit Policy manual and the Physician and professional services – telemedicine page in the MHCP Provider manual for more information.

    Managed Care Organizations

    EIDBI provider agencies that are enrolled in a health plan must follow the managed care organization’s rules and guidelines to bill, obtain authorizations and enroll with the health plan. Refer to the Managed Care Organizations (MCOs) and Prepaid Health Plans (PPHPS) page for more information.

    Special Needs BasicCare

    If a person who receives EIDBI services is enrolled in the Special Needs BasicCare program, follow fee-for-service guidelines for service authorizations.

    Definitions

    Refer to the EIDBI Benefit Policy manual for definitions.

    Legal References

    Minnesota Statutes, section 256B.0949 – Autism Early Intensive Intervention Benefit

    Approved Medicaid State Plan Amendment TN 14-08

    Additional Resources

    EIDBI Advisory Group webpage

    DHS EIDBI benefit webpage

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    Updated: 3/13/17 1:38 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 3/13/17 1:38 PM