Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit

Revised: November 7, 2022

· Overview

· Eligible Providers

· Eligible Members

· 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, review the EIDBI Benefit Policy Manual or take the EIDBI 101 training for providers. Lead agencies should review the EIDBI benefit section of the Community-Based Services manual for more information.

Overview

The Early Intensive Developmental and Behavioral Intervention (EIDBI) benefit offers medically necessary services and supports to people under the age of 21 with autism spectrum disorder (ASD) or related conditions.

The purpose of the EIDBI benefit is to:

· Educate, train and support parents and families of people with ASD and related conditions

· Promote people’s independence and participation in family, school and community life

· Improve long-term outcomes and quality of life for people and their families

Eligible Providers

To provide, bill and receive payment for EIDBI services, a provider must:

· Be enrolled as a Minnesota Health Care Programs (MHCP) provider

· Meet all applicable provider qualifications and requirements, including conducting a criminal background study using NETStudy 2.0 on all individuals, including sub-contractors, volunteers and temporary staff, who have direct contact with the person or the person's legal representative.

· Have a DHS-approved service authorization (SA) to provide EIDBI services for the person.

Refer to the Overview of EIDBI Providers webpage in the EIDBI Benefit Policy Manual for more information. Refer to the Provider Basics section of the MHCP Provider Manual for general MHCP provider requirements.

Provider Enrollment

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

Eligible Members

A person is eligible to receive EIDBI services if he or she meets all of the following criteria:

· Has 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), MinnesotaCare, Minnesota Tax Equity and Fiscal Responsibility Act (TEFRA) or other qualifying health care programs

· Is under age 21

Refer to the Eligibility for EIDBI services section of 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 – individual, group and higher intensity

· Intervention observation and direction

· Family or caregiver training and counseling

· Telehealth

· Travel time

Only eligible provider types may perform each service. Telehealth is an option for some EIDBI services. Refer to the EIDBI services section of the EIDBI Benefit Policy Manual for more information.

Noncovered Services

For a list of noncovered services, refer to the EIDBI services section of the EIDBI Benefit Policy Manual.

Access Services

EIDBI does not cover transportation and language interpreter services. As an MHCP 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.

For information on transferring agencies or coordinating EIDBI with other services, review the EIDBI services section of the EIDBI Benefit Policy Manual.

Services that Require Authorization

The following services require authorization before service delivery:

· Family or caregiver training and counseling

· Intervention – individual, group and higher intensity

· Intervention observation and direction

· Travel time

Services that Do Not Require Authorization

The following services do not require authorization before service delivery, unless the service limit thresholds outlined on the EIDBI billing grid have been exceeded. All service limits apply to the person receiving services, not the provider.

· ITP development and progress monitoring

· The Comprehensive Multi-Disciplinary Evaluation (CMDE), once per year per person without authorization. (The CMDE is not required every year, but is required at least once every three years or as clinically necessary)

· Coordinated care conferences do not require service authorization.

Process

Information in this section pertains to fee-for-service MHCP members 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. Before requesting an authorization for the first time, contact KEPRO to let them know you are a new provider and give them your National Provider Identifier (NPI) number.

Note the following timelines in the EIDBI service authorization process:

· Each EIDBI service authorization request cannot exceed a 180-day time span.

· Complete and submit a person’s annual CMDE at least 30 days, but no more than 60 calendar days, before the end date of the current service authorization period.

· The ITP and CMDE may be signed on the same day, but the ITP must not be signed before the CMDE is completed.

· KEPRO may retroactively approve up to 180 days for services that require authorization. The qualified providers and legal representative must sign the ITP and CMDE before delivering any of these services.

Responsibilities

The comprehensive multi-disciplinary evaluation (CMDE) provider is responsible to:

· Check eligibility in MN–ITS to determine whether the member is receiving EIDBI benefits through fee-for-service or is enrolled in a prepaid health plan

· Submit the completed CMDE Medical Necessity Summary Information (DHS-7108) (PDF), including the CMDE signature page, to the web-based KEPRO Atrezzo portal.

· Note: An EIDBI provider agency may submit a CMDE for medical necessity when the family or another provider gives the EIDBI provider agency a complete copy of the CMDE.

· Ensure that all documentation in the CMDE is complete and accurate before submission.

The Qualified Supervising Professional (QSP) is responsible to:

· Receive medical necessity approval before submitting the ITP

· Submit the completed Individual Treatment Plan (ITP) and Progress Monitoring (DHS-7109) (PDF), including the ITP signature page to the web-based KEPRO Atrezzo portal

· Ensure that all documentation is complete and accurate before submission

· Coordinate other health, mental health, and home and community-based services to ensure that the person receives services that are the most appropriate and effective in meeting the person’s needs

In general, the EIDBI provider agency is responsible to:

· Use the KEPRO 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.

· 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 10 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

· Put the case in pended status and notify providers through the Atrezzo message inbox if more 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 puts the case in pending status in the Atrezzo portal and requests additional information:

· The provider has 15 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.

Request Change to Approved Service Agreement

The provider may request an adjustment to an existing, approved service agreement on the ITP and submit to the medical review agent. Review the How to complete ITP and Progress Monitoring, DHS-7109 EIDBI Benefit Policy Manual webpage for instructions about how to complete this form.

Request Additional Authorization of Services

Complete and submit EIDBI Authorization Request (DHS-3806) (PDF) to request authorization for EIDBI services that exceed the service limit threshold outlined on the EIDBI billing grid (for example, additional CMDE in a calendar year). Refer to Instructions to complete the EIDBI Authorization Request form (DHS-3806A) (PDF) for instructions on how to complete and submit the form. DHS recommends a prior authorization request for these additional services; however, the medical review agent will accept authorization requests after the service is provided. Submitting a request for additional authorization of services does not guarantee an approval or MHCP payment. The medical review agent has 10 business days from when the form is received to review and make a determination.

Transition and/or Discharge from an agency

The QSP should download and complete EIDBI transition and/or discharge summary (DHS-7109A) electronically when a transition or discharge occurs. This form is optional but recommended to complete when a discharge or transition occurs. Review the How to complete ITP and Progress Monitoring, DHS-7109 EIDBI Benefit Policy Manual for instructions on how to complete the form. Submit DHS-7109A to the medical review agent or the person’s corresponding health plan. For changes to an existing service agreement, upload the form to the approved case. Be sure to adjust the units to reflect the requested changes. The medical review agent has 10 business days from when the form is received to review and make the requested changes.

Resources

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

· 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/MHCP website, Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit Atrezzo Provider Portal Submission Training and Requirements (PDF), and the Authorization section of the MHCP Provider Manual for more information.

Refer to the Comprehensive multi-disciplinary evaluation (CMDE) and the Individual treatment plan (ITP) development and progress monitoring EIDBI Benefit Policy Manual webpages for instructions on how to complete the CMDE and ITP forms.

Refer to Authorization under Provider Basics in the MHCP Provider Manual for more information.

Billing

Refer to the Billing Policy Overview section of the MHCP Provider Manual for general MHCP billing requirements.

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.

Billing when fee-for-service member has primary commercial insurance
As of Jan. 1, 2021, EIDBI providers are no longer required to bill a member’s commercial insurance carrier before billing the state for services. However, if an EIDBI agency receives payment from a different source than DHS, third party liability reporting is still required.

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 the EIDBI Claims MN–ITS User Manual

A claim submission must include:

· The pay-to provider

· The procedure code for the EIDBI service provided

· The appropriate modifiers

· The Unique Minnesota Provider Identifier (UMPI) or National Provider Identifier (NPI) of the rendering provider who delivered the service

· The supervising provider for any services that require the supervision of a QSP

All claims submitted for any services delivered by a Level III provider must have the UMPI or NPI 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

· Bill each day on a separate line in the claim.

· Use place of service (POS) 12 (home and community) for EIDBI services provided in a community setting, as outlined in the person’s Individual Treatment Plan

Tribal providers should refer to Tribal and Federal Indian Health Services in the MHCP Provider Manual for more information.

Telehealth
Certain EIDBI services are eligible to be provided via telehealth. Services provided via telehealth have the same service thresholds, reimbursement rates and authorization requirements as services delivered in-person. When services have been delivered via telehealth, the correct place of service (POS) must be provided. MHCP does not reimburse for connection charges, or origination, set-up or site fees.

Refer to:

· EIDBI telehealth services in the EIDBI Policy Manual for specific information about delivering EIDBI services via telehealth

· Telehealth services section of the MHCP Provider Manual for general telehealth information and billing instructions

· Telehealth services information in the EIDBI Provider Enrollment section of the MHCP Provider Manual to enroll to provide EIDBI services via telehealth

Resources

Refer to Billing Policy Overview under Provider Basics 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) section for more information. Refer to the EIDBI MCO Contact Information Grid (PDF) for MCO contact information.

MCOs may require that the CMDE and ITP be submitted together for authorization.

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 256B.0949 (Autism Early Intensive Intervention Benefit)
Approved Medicaid State Plan Amendment TN 17-06
Approved-Redacted Medicaid State Plan Amendment TN 18-12
Approved-Redacted Medicaid State Plan Amendment TN 19-06

Additional Resources

EIDBI advisory group webpage
DHS EIDBI benefit webpage
Brochure for EIDBI American Indian (PDF)
Brochure for EIDBI in English (PDF)
Brochure for EIDBI in Hmong (PDF)
Brochure for EIDBI in Karen (PDF)
Brochure for EIDBI in Oromo (PDF)
Brochure for EIDBI in Russian (PDF)
Brochure for EIDBI in Somali (PDF)
Brochure for EIDBI in Spanish (PDF)
Brochure for EIDBI in Vietnamese (PDF)
Minnesota Autism Resource Portal
MHCP – EIDBI Benefit Policy manual
MHCP provider directory