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

Medical necessity determination: A decision made by a qualified provider about whether a person with autism spectrum disorder (ASD) or a related condition has a medical need for, and therefore is eligible to receive, EIDBI services.

A comprehensive multi-disciplinary evaluation (CMDE) provider:

This page explains:

A person has a medical need for EIDBI services if they meet all the following criteria:

1. The person demonstrates behavioral or functional needs associated with ASD or a related condition, and those needs have a clinically significant impact on the person’s daily life, participation in their community or safety.

2. Objective clinical evidence documents that the person’s behaviors and functional needs associated with ASD or a related condition:

Note: Objective clinical evidence must support the medical necessity determination, including the identified behavioral or functional needs and their impact on the person’s daily life, participation in their community or health and safety, as applicable.

3. The qualified provider determines EIDBI services are:

4. The qualified provider expects EIDBI services to help the person:

The CMDE provider must recommend EIDBI services and treatment based on:

Medical necessity service intensity framework

The EIDBI medical necessity service intensity framework helps providers determine the person’s expected average weekly EIDBI service intensity. It uses the person’s age and overall functional impact (i.e., CMDE impact score) to identify a service intensity range.

DHS intends for the framework to both:

For more information, including instructions on how to apply the framework, refer to EIDBI – EIDBI medical necessity service intensity framework.

Exceptions

The CMDE provider may recommend treatment outside the expected service intensity range when the person’s individual clinical needs support the recommendation.

When they recommend services outside the expected range, providers must:

Once the provider submits DHS-7108 and DHS-7109 for authorization, the medical review agent evaluates the submitted documentation to determine if the requested service intensity is medically necessary. For more information, refer to MHCP Provider Manual – EIDBI – Service authorization.

The medical review agent may reauthorize EIDBI services when all the following criteria are met:

1. The ITP documents:

2. The requested treatment plan remains medically necessary and appropriate based on the person’s:

3. Documented clinical rationale supports changes to the treatment plan, including changes to:

4. The person’s parent or legal representative reviews and signs the ITP to indicate continued participation in treatment planning and consent for EIDBI services.

A qualified provider may determine a change in EIDBI service intensity is medically necessary when one or more of the following occurs:

1. The person’s functional needs, condition or level of support changes.

2. Progress monitoring indicates that the person is making greater or less progress than expected, is not making progress or is not maintaining acquired skills.

3. The person experiences a significant life event, transition or change in family or living circumstances (e.g., they start school, they change providers, they transition to other services).

4. The person’s participation in other medically necessary services changes and affects the need for EIDBI services.

5. Updated assessment findings or clinical information support a change.

6. The person’s parent or legal representative requests a change in service intensity.

The CMDE provider or QSP must document the assessment findings, objective clinical evidence and clinical rationale that supports any change in service intensity in the person’s CMDE or ITP.

For information about how to request a change in EIDBI service intensity, refer to EIDBI – Intervention.

For information about termination of EIDBI services, refer to EIDBI – Service transition, discharge and termination.