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Early Intensive Development and Behavioral Intervention Manual

Early Intensive Development and Behavioral Intervention Manual

How to complete CMDE Medical Necessity Summary Information, DHS-7108

For information about the CMDE service, refer to EIDBI – Comprehensive multi-disciplinary evaluation (CMDE). This page provides instructions to complete the related form.

Page posted: 2/17/17

Page reviewed: 7/30/24

Page updated: 7/30/24

Legal authority

CMS-approved state plan amendment – 2017 (PDF), CMS-approved state plan amendment – 2018 update (PDF), CMS-approved state plan amendment – 2019 update (PDF), Minn. Stat. §256B.0949

Definitions

Comprehensive multi-disciplinary evaluation (CMDE): An EIDBI service that covers the required comprehensive evaluation of the person. The CMDE is an assessment that must be completed to determine eligibility and medical necessity for EIDBI services, and it must be updated at least once every three years.

CMDE Medical Necessity Summary Information, DHS-7108: The form the CMDE provider uses to document and summarize the results of the person’s evaluation. The provider must submit DHS-7108 to the state medical review agent or applicable health care plan for medical necessity approval before the person can receive EIDBI services.

Overview

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

The CMDE provider must update a person’s CMDE at least once every three years or when clinically necessary, including when:

  • · Person’s condition changes.
  • · Person’s diagnosis needs to be evaluated or reevaluated.
  • · Provider receives information that requires an additional assessment.
  • · Person’s family or placement has changed.
  • · Person has a transition (e.g., transition to school, new service or new provider).
  • · Person has a significant life event (e.g., loss of family member, separation of parents).

    • The CMDE provider may complete one CMDE per year without authorization. The person’s family may request a CMDE at any time.

    The CMDE provider must:

  • · Complete all required fields.
  • · Submit the form for medical authorization by following the steps on Minnesota Health Care Programs (MHCP) Provider Manual – EIDBI service authorization.

    • For more information about how to complete the CMDE, refer to EIDBI – Individual provider trainings – CMDE and ITP Overview and the process section of EIDBI – CMDE.

    Date of CMDE

    In this section, the CMDE provider must indicate whether or not the CMDE includes all necessary components of a standard diagnostic assessment and enter one of the following dates:

  • · Initial: Date the first CMDE for the person was completed.
  • · Update: Date the CMDE was updated.
    Note: The CMDE must be updated at least once every three years.

    • If the CMDE includes the required components of a standard diagnostic assessment, the CMDE provider must enter “Yes.” The CMDE must meet all the required components of a standard diagnostic assessment if the CMDE provider delivers the person’s initial diagnosis. In other situations, a diagnostic assessment is an optional but recommended part of the CMDE.

    For more information, refer to MHCP Provider Manual – Diagnostic assessment.

    Section A: Personal information for person who receives services

    In section A, the CMDE provider must document:

  • · Person’s information (e.g., name, gender, date of birth, address, caregiver/guardian[s], living situation, household members, health insurance, race/ethnicity, language).
  • · Whether the CMDE provider used an interpreter.
    Note: If an interpreter participates, they must sign the CMDE signature page.

    • Section B: CMDE referral and provider information

    In section B, the CMDE provider must document:

  • · CMDE referral information (i.e., date of referral, person who made the referral and reason for the referral).
  • · Name and contact information of the CMDE provider.
    Note: Up to two CMDE providers may complete the evaluation.
  • · Name and contact information of the person’s primary care physician/medical provider.

    • Section C: Medical and developmental history

    In section C, the CMDE provider must describe:

  • · Person’s symptoms at baseline, including the age symptoms were first noticed and who noticed them.
  • · Person’s and family’s history and priorities, including but not limited to status of basic needs, economic status, education level, employment status, belief systems, the person’s vulnerabilities, safety needs and perception of the condition.

    • Medical history

    The CMDE provider must use the information from the medical evaluation to describe the person’s medical history. The CMDE provider must include information about:

  • · Person’s medical history and current health state, obtained from the caregiver/guardian and person’s primary physician/medical provider, including but not limited to mental status exam and any history of mental health treatment, trauma, maltreatment or abuse.
  • · Any known medical condition(s) or person’s history/exposure to alcohol or drug usage or treatment.
  • · Prior medical evaluations.
    Note: The person must have had a well-child checkup or annual physical within the last 12 months. The provider must use information from the most recent evaluations (refer to EIDBI – Medical evaluation requirements and recommendations).
  • · Current vaccinations, medications, allergies (e.g., food, respiratory, skin, medications) and hospitalizations, if applicable.

    • Developmental history

    The CMDE provider must include information about:

  • · Developmental history, including pregnancy/delivery, developmental milestones and any other significant developmental incidents or events.
  • · Person’s overall physical health and diet, including eating patterns (e.g., special diet, restrictions) and sleeping patterns.
  • · Significant events or environmental factors that may have affected the person’s development.
  • · Relevant developmental concerns and other conditions of family members (e.g., behavioral health, mental health).
  • · Person’s observed or reported strengths and resources.
  • · Person’s relationship with their family and other significant personal relationships, including the person’s evaluation of the quality of each relationship.
  • · Family’s observed or reported strengths, including cultural influences and impact.

    • Section D: Observation

    As part of the CMDE process, the enrolled CMDE provider (not the clinical trainee) must complete at least one observation of the person. The clinical trainee may complete an additional observation.

    The observation must:

  • · Be conducted in person or via telehealth by an MHCP-enrolled CMDE provider.
  • · Be completed within 60 days of the CMDE date (i.e., date the final person signs the document).
  • · Describe the person’s symptoms, physical health, appearance and overall development.

    • The observation may also include:

  • · Identification of the person’s potential developmental objectives on which to focus when creating goals.
  • · Evaluation of the person’s response to questions, instructions or transitions.
  • · Identification of how the person communicates (e.g., requests, labels, gestures, points, pulls adult to what they need or want, sign language, pictures, crying, grabbing).
  • · Evaluation of other language (e.g., expressive and receptive language, imitation, echolalia, intra-verbal communication).
  • · Evaluation of play skills by observing the person play independently, cooperatively or parallel to peers or family members (e.g., imitates the play of others, takes turns).
  • · Description of the person’s overall physical health and appearance.
  • · Identification of strengths and skills on which the person can build.

    • In section D, the CMDE provider must document:

  • · Observation results and summary.
  • · Observation date and setting (i.e., telehealth, clinic, home, center, school). For more information, refer to EIDBI – Settings.
  • · Person who completed the observation.

    • DHS recommends completing a second observation in a second setting. The second observation may be completed by a provider who is not enrolled as an EIDBI or MHCP provider (e.g., teacher, speech therapist). If another observation is completed, the CMDE provider must document it in the CMDE.

    Section E: Summary of developmental domains

    In section E, the CMDE provider must document the person’s level of functioning in the following developmental domains:

  • · Social interaction.
  • · Social communication.
  • · Restricted or repetitive behaviors or interests.
  • · Self-care skills.
  • · Interfering or unwanted behaviors.
  • · Expressive communication.
  • · Receptive communication.
  • · Cognitive functioning.
  • · Safety.
  • · Learning, play and motor skills.
  • · Behavior and sensory regulation.

    • The CMDE provider must score each developmental domain based on information from:

  • · Standardized assessments.
  • · Chronological age.
  • · Additional reports.
  • · Clinical judgement.
  • · Formal and informal assessment tools.
  • · Medical and developmental history, including impact of any co-occurring conditions.
  • · Observations across different settings, people and situations.
  • · Parent, caregiver or guardian interviews.

    • The CMDE provider must use the following scores for each domain:

  • · Tier I or a score of 0: Little to no support needed.
  • · Tier II or a score of 1: Minimal support or accommodations needed.
  • · Tier III or a score of 2: Moderate support or accommodations needed.
  • · Tier IV or a score of 3: Substantial support or accommodations needed.

    • The CMDE provider can use the following information to further define support levels:

  • · Little to no support needed: The person demonstrates skills or completes most tasks independently. They use universal supports found in the natural environment or available to all people.
  • · Minimal support needed: The person needs some assistance, reminders or supports. They may need verbal or visual accommodations, especially for organization or planning. They demonstrate several skills or complete several tasks independently, or they can fade assistance quickly.
  • · Moderate support needed: The person needs moderately intensive (1:1 or small group) and targeted supports or assistance to complete most tasks or activities of daily living (ADLs). Interfering behaviors affect some situations. Communication differences and restricted or repetitive behaviors or interests affect their learning and development in many situations.
  • · Substantial support needed: The person needs assistance to complete almost all tasks or ADLs. Interfering behaviors affect their daily living and participation in home and community life. They need highly intensive (1:1) and individualized supports. Communication differences and restricted or repetitive behaviors or interests affect their learning and development in most situations.

    • The CMDE provider uses these summary results (i.e., “impact scores”) to recommend medically necessary treatment. For more information, refer to EIDBI – Medical necessity criteria.

    Section F: Caregiver/guardian informational interview

    As part of the CMDE process, the CMDE provider must interview at least one of the person’s caregivers/guardians.

    Based on the interview, observations and clinical judgement, the CMDE provider must score each of the following caregiver/guardian domains:

  • · Confidence.
  • · Stress.
  • · Perception of quality of life.

    • The CMDE provider should include any additional feedback from the caregiver/guardian or explanation of their scores.

    Section G: Summary of referrals made

    In section G, the CMDE provider must document:

  • · Referrals the CMDE provider makes for other services.
  • · Reason(s) for referrals.
  • · Coordination of services the person currently receives.

    • Potential referrals may include but are not limited to:

  • · Case manager or social worker.
  • · Speech and language therapy.
  • · Occupational therapy.
  • · Other interventions and services (refer to MN Autism Resource Portal – Programs and services).

    • It may also be appropriate to refer families to support groups, advocates and other community-based supports (refer to MN Autism Resource Portal – Supports).

    If the CMDE provider does not include any referrals, they must include the reason no referrals were made or necessary at this time.

    Section H: Diagnostic information, summary of clinical findings, assessment results and treatment recommendations

    In section H, the CMDE provider must document the following information.

    Diagnostic information

    The CMDE provider must:

  • · Include whether the person meets DSM-V criteria by reviewing or completing a diagnostic assessment (refer to MHCP Provider Manual – Diagnostic assessment).
  • · Perform, review and rely on information and assessments for the person’s eligibility determination, treatment and service recommendations and individual treatment plan (ITP) development if delivering an initial diagnosis. When completing a standard diagnostic assessment of a person, the provider must use a recognized diagnostic framework. For diagnostic criteria and information about assessment tools, refer to EIDBI – Eligibility for services.
  • · List the primary diagnosis and any additional diagnoses, as applicable, for medical necessity and service coordination purposes.
  • · List diagnostic code(s) using the current International Classification of Diseases (ICD) code(s).
  • · Document the provider’s use of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Childhood (DC: 0-5R), if applicable.
  • · Document the person’s accompanying intellectual disability or language impairment, if applicable.

    • Assessment tools

    The CMDE provider must include the results of any ASD, IQ/developmental, cognitive and adaptive behavior or other assessment tools used.

    Notes:

  • · DHS strongly encourages the use of standardized assessment tools to diagnose and evaluate cognitive/intellectual, adaptive and sensory regulatory abilities. However, DHS does not require specific assessment tools unless the CMDE meets the requirements of a diagnostic assessment (refer to MHCP Provider Manual – Diagnostic assessment).
  • · If the person is age five or older and/or the provider makes a referral for waiver case management services, DHS strongly recommends including the results of both a cognitive and adaptive behavior assessment.

    • Summary of clinical findings

    The CMDE provider must:

  • · Include a clinical summary of how the person meets the diagnostic criteria, including functional impact of symptoms, level of support needed and medical necessity rationale for services.
  • · Explain the person’s strengths, cultural influences, life situations, relationships, health concerns and how the diagnosis affects the person’s life.
  • · Include a summary of treatment recommendations, prioritization of services and other referrals.

    • Note: If the CMDE provider uses a previous diagnostic assessment from another provider or agency, they must include a summary of the overall results. The CMDE provider must review the previous diagnostic assessment to confirm the person has an eligible diagnosis and the diagnostic assessment meets standards in Minn. Stat. §245I.10, subd. 6. If the provider chooses to complete the diagnostic assessment at the same time as the CMDE, they must certify that the CMDE meets all required standards.

    EIDBI treatment recommendations

    The CMDE provider must base their treatment recommendations on medical necessity. For guidelines, refer to EIDBI – Medical necessity criteria.

    The CMDE provider must document:

  • · Caregiver/guardian’s preference for training and counseling.
  • · Provider’s recommendation for family/caregiver training and counseling.
  • · Provider’s recommendation for intervention services.

    • The provider’s family/caregiver training and counseling recommendation must include:

  • · Weekly range of service intensity
    Note: The recommendation must include a minimum and maximum number of hours.
  • · Setting(s) in which the family/caregiver should receive training and counseling.

    • The provider’s intervention recommendation must include:

  • · Range of service intensity the provider assesses as clinically necessary for the person to progress per week.
    Note: The recommendation must include a minimum and maximum number of hours.
  • · 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, refer to EIDBI – Settings.
  • · Information and recommendation about the range of current EIDBI treatment modalities. For information about the current EIDBI modalities, refer to EIDBI – Treatment modalities.

    • Exceptions to medical necessity treatment guidelines

    If the CMDE provider recommends an exception to guidelines listed on EIDBI – Medical necessity treatment determination guidelines, they must provide clear rationale and supporting documentation. This could include information from other qualified professionals who work with the person and family.

    For more information, refer to EIDBI – Medical necessity criteria.

    CMDE signature page

    Once DHS-7108 is complete, the following people must sign and date the CMDE signature page:

  • · CMDE provider(s).
  • · CMDE clinical trainee (if applicable).
  • · Caregiver/guardian(s).
  • · Interpreter (if applicable).

    • The signatures and dates must either:

  • · Be handwritten.
  • · Use an approved electronic signature with a time and date stamp (refer to MHCP Eligibility Policy Manual – Signature).

    • If a CMDE clinical trainee under supervision completes the CMDE, the provider must list the CMDE supervisor as the primary CMDE provider (refer to EIDBI – CMDE provider qualifications, roles and responsibilities).

    The signatures serve as consent for the person to begin receiving EIDBI services.

    Note: Only people who can consent to treatment and make legal decisions can sign the form. This may not include all caregivers. The provider must make sure each person who signs the form has the legal authority to do so.

    Timeline

    The evaluation is considered complete on the date the last person signs the CMDE.

    The CMDE may be completed and signed on the same day as the ITP, but the CMDE cannot be completed after the ITP.

    Translated signature pages

    Hmong: CMDE kos npe (Daim Ntawv Txuas Ntxiv A), DHS-7108S-HMN (PDF)
    Russian: Подписи CMDE (Дополнение A), DHS-7108S-RUS (PDF)
    Somali: Saxiixyada CMDE (Lifaaqa A), DHS-7108S-SOM (PDF)
    Spanish: Firmas CMDE (Anexo A), DHS-7108S-SPA (PDF)
    Vietnamese: Các chữ ký CMDE (Phụ lục A), DHS-7108S-VIE (PDF)
    Note: The English version is included in CMDE Medical Necessity Summary Information, DHS-7108.

    Additional resources

    CMDE Medical Necessity Summary Information, DHS-7108
    EIDBI – CMDE
    EIDBI – Eligibility for services
    EIDBI – Medical necessity criteria

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