Chapter : Covered Services and Limitations (Early Intervention)
Freedom of Choice (EI)
According to federal requirements (Section 1902(a)(23) of Title XIX of the Social Security Act (the Act)), Medicaid (including Family Access to Medical Insurance Security Plan (FAMIS) Plus and FAMIS) eligible individuals must be offered a choice of service provider(s) and this must be documented in the individual’s file.
General Information (EI)
Medicare Catastrophic Coverage Act of 1988
The Medicare Catastrophic Coverage Act of l988 and other legislation require State Medicaid Programs to expand the coverage of services to certain low-income Medicare beneficiaries, known as Qualified Medicare Beneficiaries (QMB’s).
QMB Coverage Only
Individuals in this group are eligible for Medicaid coverage of Medicare premiums and of deductibles and coinsurance up to the Medicaid payment limit, less the individual's co-payment on allowed charges for all Medicare-covered services. Their Medicaid verification will provide the message "QUALIFIED MEDICARE BENEFICIARY--QMB." The Medicare coinsurance is limited to the Medicaid fee when combined with the Medicare payment.
QMB Extended Coverage
Individuals in this group will be eligible for Medicaid coverage of Medicare premiums and of deductibles and coinsurance up to the Medicaid payment limit on allowed charges for all Medicare-covered services plus coverage of all other Medicaid-covered services listed in Chapter I of this manual. This group’s Medicaid verification provides the message, "QUALIFIED MEDICARE BENEFICIARY--QMB EXTENDED." These individuals are
responsible for copays for pharmacy services, health department clinic visits, and vision services.
Individuals without either of these messages on their Medicaid cards will be eligible for those covered services listed in Chapter I of this Manual.
The Early Periodic Screening Diagnosis and Treatment (EPSDT) benefit is Medicaid’s comprehensive and preventive child health program for children under the age of 21. Federal law (42 CFR § 441.50 et seq) requires a broad range of outreach, coordination, and health services under EPSDT distinct from general state Medicaid program requirements. EPSDT is geared to the early assessment of children’s health care needs through periodic screenings. The goal of EPSDT is to assure that health problems are diagnosed and treated as early as possible, before the problem becomes complex and treatment costlier. Examination and treatment services are provided at no cost to the individual.
Any treatment service which is not otherwise covered under the State’s Plan for Medical Assistance can be covered for a child through EPSDT as long as the service is allowable under the Social Security Act Section 1905(a) and the service is determined by the Department of Medical Assistance Services (DMAS) or its agent as medically necessary. Early Intervention (EI) services are targeted toward treating children under three (3) years of age.
Early Intervention Definition
Virginia’s EI system is implemented by the Department of Behavioral Health and Developmental Services (DBHDS). Federally, EI services are governed by the Part C of the Individuals with Disabilities Education Act (IDEA) (20 U.S.C. § 1431 et seq.).
EI services are developmental supports and services that are performed in natural environments, including home and community based settings in which children without disabilities participate, to the maximum extent possible. Services are designed to meet the developmental needs of an infant or toddler with a developmental delay and the needs of the family related to enhancing the child’s development, as identified by the Individualized Family Service Plan (IFSP) team, in any one or more of the following areas: physical development, cognitive development, communication development, social or emotional development, and adaptive development in order to promote:
- Positive social-emotional skills and relationships,
- Acquisition and use of new knowledge and skills, and
- Use of appropriate behaviors to meet needs (taking actions to get needs met).
Specific services are determined through a collaboration of the child’s parent(s) or guardian, and the child’s multidisciplinary Individualized Family Services Plan (IFSP) team. Through the IFSP process the services needed to meet the child’s intended outcomes are identified and are based on the results of the child assessment and the family/caregiver concerns, resources and priorities. Services may be provided by a variety of Certified Early Intervention Practitioners.
Children (0-3 years of age) who are eligible for Medicaid/ FAMIS Plus, or FAMIS may be screened for EI services. Below is a clarification of eligibility within the different programs and delivery systems.
Children who are enrolled in Medicaid’s FAMIS Select program are not eligible for reimbursements through the DMAS EI services program.
Family Access to Medical Insurance Security Plan (FAMIS)
Most FAMIS benefits are administered through DMAS contracted MCOs. FAMIS enrollees who are not enrolled with a DMAS contracted MCO receive services directly through DMAS as a FFS benefit. FAMIS MCO and FAMIS FFS individuals are eligible for EI services.
Medicaid/FAMIS Plus and FAMIS Coverage of Early Intervention Services
EI services are available to Medicaid/FAMIS Plus/FAMIS enrollees. Children must meet the eligibility criteria for the EI services through the Infant & Toddler Connection of Virginia (Part C program) at DBHDS. Transportation for EI services is covered and must be arranged through Logisticare.
Medicaid MCO Coverage of Early Intervention Services
All EI services are carved-out of the Medicaid MCO contract and are covered through the DMAS fee-for-service provider network in accordance with DMAS fee-for-service established coverage criteria and guidelines. Transportation is covered by the Medicaid MCOs for EI services. Transportation must be arranged through the individual MCO.
FAMIS MCO Coverage of Early Intervention Services
All EI services are carved-out of the FAMIS MCO contract and are covered through the DMAS fee-for-service provider network in accordance with DMAS fee-for-service established coverage criteria and guidelines. Since transportation is not a covered service for those in FAMIS MCOs, the MCO is not responsible to cover transportation for carved-out services. However, transportation is covered for EI enrollees who are enrolled in FAMIS FFS and must be arranged through Logisticare.
Virginia Early Intervention Eligibility Criteria
Infants and toddlers, birth to three (3) years old, are eligible for EI supports and services through the Infant & Toddler Connection if they meet one or more of the following criteria:
- Developmental Delay – Children (0-3 years of age) who are functioning at least 25% below their chronological or adjusted age in one or more of the following areas:
- Cognitive development;
- Physical development, including fine motor and gross motor;
- Communication development;
- Social or emotional development; or
- Adaptive development.
For children born prematurely (gestation < 37 weeks), the child's adjusted age is used to determine developmental status. Chronological age is used once the child is 18 months old.
- Atypical Development – Children (0-3 years of age) who manifest atypical development or behavior, which is demonstrated by one or more of the following criteria (even in the absence of a 25% developmental delay):
- Atypical or questionable motor responses, such as:
- Abnormal muscle tone;
- Limitations in joint range of motion;
- Abnormal reflex or postural reactions;
- Poor quality of movement patterns or quality of skill performance; or
- Oral-motor skills dysfunction, including feeding difficulties.
- Atypical or questionable social-emotional development, such as:
- Atypical or questionable motor responses, such as:
- Delay or abnormality in achieving expected emotional milestones;
- Persistent failure to initiate or respond to most social interactions;
- Fearfulness or other distress that does not respond to comforting by caregivers.
- Atypical or questionable behaviors that interfere with the acquisition of developmental skills.
- Impairment in social interaction and communication skills along with restricted and repetitive behaviors.
- Children (0-3 years of age) with a diagnosed physical or mental condition that has a high probability of resulting in a developmental delay. These conditions include, but are not limited to the following:
- Seizures with significant encephalopathy;
- Significant central nervous system anomaly;
- Severe Grade 3 intraventricular hemorrhage with hydrocephalus or Grade 4 intraventricular hemorrhage;
- Symptomatic congenital infection;
- Effects of toxic exposure including fetal alcohol syndrome, drug withdrawal and exposure to chronic maternal use of anticonvulsants, antineoplastics, and anticoagulants;
- Congenital or acquired hearing loss;
- Visual disabilities;
- Chromosomal abnormalities, including Down Syndrome;
- Brain or spinal cord trauma, with abnormal neurologic exam at discharge;
- Inborn errors of metabolism;
- Severe attachment disorders;
- Failure to thrive;
- Autism spectrum disorder;
- Endocrine disorders with a high probability of resulting in developmental delay;
- Hemoglobinopathies with a high probability of resulting in developmental delay;
- Cleft lip or palate; or
- Periventricular leukomalacia;
- Neonatal factors that make developmental delay highly probable:
- Gestational age ≤ 28 weeks, or
- NICU stay ≥ 28 days; or
- Other physical or mental conditions at the multidisciplinary team members' discretion.
Children are not eligible to receive Early Intervention Services on or after their third birthday
(according to 12VAC35-225-70).
Early Intervention Services
Service Definitions and Criteria
EI services that are reimbursed by DMAS are defined as:
- Assessment and intervention services to address the functional developmental needs of an infant or toddler with a disability with an emphasis on a variety of developmental areas including, but not limited to, cognitive processes, communication, motor, behavior and social interaction. The infant or toddler must have been found eligible to receive EI services in order for the assessment and intervention to be covered by DMAS;
- Collaboration with the family, service coordinator and other EI service providers identified on an infant’s or toddler’s IFSP;
- Consultation to design or adapt learning environments, activities and materials to enhance learning opportunities for an infant or toddler with a disability;
- Family training, education and support provided to assist the family of an infant or toddler with a disability in understanding his or her functional developmental needs and to enhance
his or her development.
Individualized Family Service Plan
EI services are determined by the family-centered Individualized Family Service Plan (IFSP) team based upon the child’s developmental status and unique needs, and upon the family’s concerns, resources, and priorities. Services are multidisciplinary in nature and focus on maximizing the child’s developmental and functional skill acquisition, to include quality, intentionality and generalization, through individual child interventions, which include coaching, modeling and education with the family/caregivers through typical routines and activities within the daily environment of the child.
Effective early intervention requires an active family/caregiver-provider partnership that includes active participation of the family/caregiver in each EI session. The focus is on expanding the parents’/caregivers’ confidence and competence to help the child learn during everyday activities.
The IFSP team must include the involvement of the family/caregiver and two or more individuals from separate disciplines or professions and one of these individuals must be the service coordinator.
Each IFSP lists the service(s) necessary to meet the child’s outcomes. Below is a list of services available for reimbursement to children in the EI program. The list has been divided to clarify which services are included in the services covered through the DMAS EI program and which services are billed separately from the EI program.
Covered services through the DMAS EI program include:
- Case Management / Service Coordination;
- Developmental services;
- Speech-language pathology, including sign language and cued language services;
- Nursing services;
- Occupational therapy;
- Physical therapy;
- Psychological services;
- Social work services; and
- Assistive technology related services (such as instruction or training on use of assistive technology).
Services below are covered by DMAS (for fee-for-service members) or the Managed Care Organizations (MCOs) (for MCO enrolled members) and are not billed as part of the DMAS EI program:
- Assistive technology devices;
- Health services;
- Nutrition services;
- Medical services, only for diagnostic or assessment purposes;
- Audiology services, and
- Vision services.
See Appendix B in this manual for definitions of the above services and each specific provider manual for additional information.
Medical Necessity Criteria and Physician Certification
The Local Infant & Toddler Connection Systems use a multidisciplinary team to determine if a child meets the Virginia EI eligibility criteria which include delayed development, atypical development and/or a diagnosed medical (physical or mental) condition that has a high probability of resulting in developmental delay. After the child is determined eligible for EI services, a multidisciplinary team reviews existing medical and developmental information and conducts observation and assessment of the eligible child to determine the child’s strengths and needs in all areas of development and assist the IFSP team in identifying the EI supports and services necessary to address the child’s unique needs.
The IFSP is developed through a family-centered team planning process in which the family is supported to participate as an equal team member. The child’s family helps the IFSP team and service providers understand the child’s and family’s daily routines and activities. The providers then assist the family in recognizing and utilizing existing learning opportunities and creating new ones that will help the child reach the desired outcomes. The resulting IFSP reflects the family’s priorities, resources, and concerns; the child’s functional strengths and needs; the outcomes the family would like to see for their child and family; and the supports and services necessary to achieve those outcomes.
A multidisciplinary team (two or more individuals from separate disciplines or professions and one of these must be the service coordinator), which includes the family/caregiver, must develop the IFSP. The IFSP shall describe the developmental service needs and the amount, duration, and scope of EI services determined necessary by the IFSP team. Medical necessity for EI services is defined by the IFSP combined with a physician, physician’s assistant, or nurse practitioner who must certify the IFSP within 30 days after the first IFSP service begins (does not include service coordination). Children who have an IFSP signed by the parent or legal guardian are eligible to receive services immediately.
Physician, physician assistant, or nurse practitioner certification is required for services listed on the initial IFSP, annual IFSPs and any time services change (as determined through the IFSP Review process). Service changes include a change in the frequency, length, intensity, duration, or type of EI service and/or discipline. The IFSP must be certified by the physician, physician assistant, or nurse practitioner as a whole (i.e. it is not acceptable to have more than one individual or agency obtain certification for individual services on the IFSP). If the IFSP (including initial, annual, IFSP Reviews) is not certified by a physician, physician assistant or nurse practitioner signature within 30 days of the date of the first visit for the service(s) listed on the IFSP, services provided prior to the certification date are not eligible for DMAS reimbursement. This includes changes in services as determined through the IFSP review process. The certification of the IFSP is important for the health and welfare of the EI member. While the responsibility of obtaining the physician, physician assistant, or nurse practitioner certification may be delegated to one individual/agency, all practitioners involved in the care of the child must ensure that the certification is obtained within the required timeline.
Assessments for children who are found eligible for EI services are covered regardless of whether the family chooses to receive EI services and in absence of an IFSP. Providers must keep the completed Eligibility Determination Form and the documentation of the assessment for service planning. Assessments and Service Coordination services do not require a certification from the physician, physician’s assistant, or nurse practitioner.
Early Intervention Services and Other DMAS Covered Services
Children in the EI program may also be enrolled in a Medicaid home and community-based waiver program. Children may also be appropriate for services provided through the Money Follows the Person program if they meet the eligibility requirements. In addition, children in the EI Program may also receive hospice services if they are determined eligible.
Service Limitations (EI)
EI services shall be recommended by the child’s primary care provider or other qualified EPSDT screening provider as necessary to correct or ameliorate a physical or mental condition. The recommendation is demonstrated by a signature on the IFSP, the IFSP summary form, or the certification form that indicates the screener has reviewed the IFSP. An EPSDT screener must be a physician, physician’s assistant, or nurse practitioner.
EI services shall be provided in settings that are natural or normal for an infant or toddler without a disability, such as the home, unless there is justification for an atypical location documented in the child’s IFSP. If a service is listed on the IFSP to be provided in a natural or normal setting and because of unusual circumstances a session is provided in an atypical
location, the provider must document this occurrence in the enrollee’s record. The specific reason for the change must be clearly documented. An IFSP Review must occur whenever an ongoing change to the location of services specified in the IFSP is being considered.
Coverage for EI services shall include an assessment by certified EI Professionals to define developmental service needs for the IFSP. See Appendix G of this manual for information on which type of provider is eligible to perform assessments. All EI services must be provided by individual practitioners who are certified as EI practitioners. All EI services must be provided to children who have an IFSP and who are enrolled with DMAS to receive EI services.
Billable time consists of actual time spent with the child and family member or caregiver, with the exception of EI targeted case management/service coordination. The family member or caregiver must physically be present and actively participate in the intervention session in order for the session to be reimbursed. The goal of the EI program is for the parent or authorized caregiver to learn from interactive participation with the practitioner and the child in order to be confident and competent in implementing the intervention strategies in the child’s and family’s typical routines, in-between visits from the practitioner. Documentation must reflect the interactive participation between the practitioner, caregiver and child.
EI services shall be provided at the frequency and length listed on the IFSP. If a service is not provided at the frequency and length listed on the IFSP due to unusual circumstances (such as making up for a missed visit), the provider must document this occurrence in the enrollee’s record. The specific reason for the change in frequency and/or length must be clearly documented. An IFSP Review must occur whenever an ongoing change to the frequency or length of services specified in the IFSP is being considered.
- Services not listed on the IFSP (other than service coordination, assessments and IFSP meetings);
- Sessions that are conducted for family support unrelated to the IFSP, education, recreational, or custodial purposes, including respite or child care;
- Services provided by a relative who is legally responsible for the child’s care;
- Services rendered in a clinic or provider’s office without justification for the location;
- Services provided in excess of the frequency, length, or duration as specified on the IFSP without acceptable justification;
- Services provided in the absence of the child and/or a family member or other authorized caregiver (other than IFSP meetings); and
- Provider travel time.
Early Intervention Targeted Case Management/Service Coordination
EI Targeted Case Management (also referred to as EI Service Coordination) is a service that will assist the child and family in gaining access to needed and appropriate medical, social, educational, and other services. EI Service Coordination is designed to ensure that families are receiving the supports and services that will help them achieve their goals on their child’s Individual Family Service Plan (IFSP), through monthly monitoring, quarterly family contacts, and on-going supportive communication with the family.
EI Service Coordination Allowable Activities
EI Service Coordination allowable activities include, and are not limited to:
- Coordinating the initial Intake and Assessment of the child and planning services and supports, to include history-taking, gathering information from other sources, and the development of an IFSP, including initial IFSP, periodic IFSP reviews, and annual IFSPs. This does not include performing medical assessments, but may include referral for such assessment;
- Coordinating services and supports planning with other agencies and providers;
- Assisting the child and family directly for the purpose of locating, developing, or obtaining needed services and resources;
- Enhancing community integration through increasing the child and family’s community access and involvement;
- Making collateral contacts to promote implementation of the IFSP and allow the child/family to participate in activities in the community. A collateral contacts is defined as “Contacts with the child’s significant others to promote implementation of the service plan and community participation, including family, non-family, health care entities and others related to the implementation and coordination of services”;
- Monitoring implementation of the IFSP through regular contacts with service providers, as well as periodic EI visits;
- Developing a supportive relationship with the family that promotes implementation of the IFSP and includes coaching the family in problem-solving and decision-making to enhance the child’s ability to participate in the everyday routines and activities of the family within natural environments where children live, learn, and play;
- Coordinating the child/family’s transition from Part C EI services at age 3; and
- Contacts (face to face, phone, email, or text) with the family every three calendar months.
EI Service Coordination Documentation Requirements
EI Service Coordination documentation requirements include:
- Initial EI Service Coordination Plan signed by required parties;
- IFSP completed and signed by required parties, including IFSP reviews and Annual IFSPs;
- Contact Notes of all allowable activities written within five (5) business day of services rendered.
- Documentation of rights and procedural safeguards and Medicaid right to appeal; and
- The length of time documented in minutes that the service coordinator spent rendering service coordination activities.
EI Service Coordination Requirements of Family Contacts using Texting
EI Service Coordination requirements of family contacts using texting include:
- The service coordinator may only offer texting as an option if he/she has the capability to receive and send texts;
- If the family chooses to communicate with texting, the parent or caregiver must sign the Permission for Texting form. The form notifies the family that there may be some level of risk that the information in the text may be read by a third party. The Permission for Texting form must be kept in the child’s Early Intervention Record. The Permission for Texting form may be found in the appendices of this manual (See Appendix J);
- The communication that occurs via texting must constitute service coordination. Sending a text to the family to ask how things are going and getting a reply of “Fine” is not service coordination. That is true for contacts via email, phone, or in person as well. The job of service coordination does not change based on the preferred method of contact. For that reason, contact notes must substantiate that the communication between the service coordinator and the family is substantive and does constitute actual service coordination;
- The service coordinator must either print out and attach a copy of the texts to the contact note or include in the note a thorough summary of the communication; and
- If, at any point, it becomes clear that texting is not a viable method of communication with a particular family, then the service coordinator needs to work with the family to identify a different method of contact.
Third Party Liability (TPL) Exclusion for EI Service Coordination
EI Service Coordination providers should not bill an EI enrollee’s private insurer or other TPL for Service Coordination. TPL is excluded from EI evaluations, assessments, IFSP meetings, Developmental Services and Service Coordination. Providers are required to bill TPL for other EI services provided by Physical Therapists (PT), Occupational Therapists (OT), Speech Language Pathologists (SLP), and Registered Nurses (RN).
Other Medicaid Targeted Case Management (TCM) / Service Coordination (SC) Services
As of October 1, 2011 EI Service Coordination became a required service for all Medicaid and FAMIS Early Intervention enrollees. Intellectual Disability (ID) TCM, Serious Emotional Disturbances (SED) TCM, or Mental Health (MH) TCM cannot be billed for EI enrollees.
Individuals who are enrolled in the Therapeutic Foster Care (TFC) program may continue to be enrolled in that program but the EI Service Coordinator and the TFC case manager must communicate to coordinate services provided to the family and must determine which case management service will be billed to DMAS. Both EI Service Coordination and TFC case management cannot be billed to DMAS for the same service month for the same enrollee.
In such situations where it is not permissible to bill DMAS for EI Service Coordination, other funds (including Part C funds as payer of last resort) may be used to cover the costs of service coordination.
Medicaid BabyCare Program
EI enrollees who are also enrolled in the Medicaid BabyCare program may continue to receive BabyCare services, which includes case management. (Medicaid MCOs have their own high risk infant case management program.) Infants are enrolled in the BabyCare program because they are at risk for poor birth/health outcomes. An infant may receive BabyCare services up to their second birthday. BabyCare case management providers are primarily Registered Nurses or Social Workers at the local health department.
The BabyCare case manager is responsible for completing a comprehensive assessment specific to the BabyCare program and a service plan, which may include the health needs of the mother as well as the infant. If an infant enrolled in the BabyCare program appears to not be developing as expected, or has a medical condition that can delay normal development, the BabyCare case manager is responsible for working with the family to initiate a referral for evaluation and assessment through the EI program. If the infant is receiving case management services through BabyCare and EI services, the EI Service Coordinator and the BabyCare case manager will need to coordinate services to ensure that there is no duplication.
For more information on the BabyCare case management service, see the DMAS BabyCare manual, Chapter IV. EI TCM will be reimbursed by DMAS separately from all BabyCare services, even during the same calendar month.
Enrollment Process (EI)
EI services do not require prior authorization through DMAS. EI Service Coordination is reimbursable by DMAS prior to determination of EI eligibility. The Assessment for Service Planning and the IFSP meeting are reimbursable by Medicaid prior to the IFSP date. Development of the IFSP and annual IFSPs, as well as IFSP reviews shall be covered if these include face to face participation of the family.
The EI benefit will be entered in the Medicaid data system (VaMMIS) after the initial intake visit for those children who have Medicaid/FAMIS coverage at the time, or as soon as Medicaid/FAMIS eligibility is determined for those who obtain Medicaid/FAMIS coverage after the intake visit.
Initial EI Service Coordination
EI Service Coordination services may be initiated and will be reimbursed by DMAS while EI eligibility is being determined by the Infant & Toddler Connection of Virginia (local system) for children who have Medicaid/FAMIS coverage. This includes those children for whom Medicaid/FAMIS coverage was not in place initially, but was retroactive to include the date of the initial intake visit.
The Initial Early Intervention Service Coordination Plan is in effect and, therefore, EI Service Coordination may be billed from the date of the initial intake visit up to one of the following three dates, whichever occurs first:
- The Part C Eligibility Determination Date for children determined ineligible for EI;
- The date the IFSP is signed; or
- 90-days from the EI Intake Date when EI eligibility has not been determined or an IFSP has not been developed within 90-days from the EI Intake date.
Note: After development of the IFSP, ongoing EI Service Coordination Services are provided and may be reimbursed by DMAS until the child is discharged from the Early Intervention Services.
Reimbursement for EI Service Coordination may come from either DMAS or other funding sources, depending on whether the child is/becomes Medicaid/FAMIS eligible.
- If the child has Medicaid/FAMIS at the time of the EI Intake Date, reimbursement will be from DMAS, whether the child does or does not become EI eligible. Reimbursement for this eligibility determination period of time requires the completion of the Initial EI Service Coordination Plan form by the EI Service Coordinator.
- If the child does not have Medicaid/FAMIS at the time of the EI Intake Date, reimbursement will be from DMAS only if the child becomes Medicaid/FAMIS eligible and the child’s Medicaid/FAMIS is retroactive to the Intake Date, as long as there is a signed Initial Early Intervention Service Coordination Plan in place. If the child does not have Medicaid/FAMIS at the time of the EI Intake Date and the child does not become Medicaid/FAMIS eligible, other funding sources must be used. Reimbursement for eligibility determination requires implementation of an Initial Early Intervention Service Coordination Plan at intake.
After the Initial Intake the Local Lead Agency (LLA) must record the Initial Intake Visit Date into the Infant and Toddler Online Tracking System (ITOTS) data system. For more information about ITOTS, you may go to: http://www.infantva.org. Once the Medicaid/FAMIS Plus or FAMIS child is enrolled in the EI program, EI Service Coordination can be billed and reimbursed by DMAS as long as all requirements are met.
LLAs must follow the Infant & Toddler Connection of Virginia Practice Manual procedures for data entry and notification to the Part C Office for activating and/or ending the EI benefit in the VaMMIS. The Infant & Toddler Connection of Virginia Practice Manual can be accessed at www.infantva.org.
The following programs are ways to inquire about the status of the child’s eligibility: Virginia Medicaid Web Portal
The Virginia Medicaid Web Portal is the gateway for providers to transact all Medicaid and FAMIS business via one central location on the Internet. The web portal will provide access to Medicaid Memos, Provider Manuals, provider search capabilities, provider enrollment applications, training and education. Providers must register through the Virginia Medicaid Web Portal in order to access and complete those secured transactions listed below. The new Virginia Medicaid Web Portal can be accessed by going to: www.virginiamedicaid.dmas.virginia.gov.
The following transactions are available to registered users:
- Check Medicaid and FAMIS Member Eligibility.
- Check Medicaid and FAMIS Member Service Limits.
- Check the Status of a Submitted Claim.
- Check a Weekly Medicaid and FAMIS Payment Amount.
- Check on a Member Service Authorization.
First Time Registrations to the Virginia Medicaid Web Portal
First time users must navigate to the new Virginia Medicaid Web Portal at www.virginiamedicaid.dmas.virginia.gov and establish a user ID and password. By registering, individuals are acknowledging that they are the staff member who will have administrative rights for their organization. Answers to any questions regarding the registration process may be located on the Web registration reference materials available on the Web Portal. If further assistance is required, please contact the Web Registration Support Call Center, toll free at 1- 866-352-0496, from 8:00 A.M. to 5:00 P.M. Monday through Friday, except holidays.
DMAS has contracts with the following eligibility verification vendors offering internet and/or integrated platforms. Eligibility details such as eligibility status, third party liability, limits for many service types and procedures are available. Contact information for each of listed below.
1 (888) 661-5657
SIEMENS Medical Solutions – Health Services
Foundation Enterprise Systems/HDX www.hdx.com
1 (610) 219-2322
Emdeon www.emdeon. Telephone:
1 (877) 363-3666
The eligibility vendor contact information is also available on the DMAS website: http://dmasva.dmas.virginia.gov.
Early Intervention Reimbursement
All providers who wish to provide EI services must be certified by DBHDS as an EI provider. To be reimbursed for services rendered, each provider must have a valid signed provider agreement and a valid NPI or API number with DMAS for the type of services to be provided. See Chapter II of this manual for details about provider enrollment.
Reimbursement codes for EI services should be chosen based on the service and the type of EI certified practitioner providing the service. The certified practitioners are categorized as either Reimbursement Category 1 or 2 (See Appendix G).
The EI program uses nine different procedure codes with modifiers to trigger reimbursement processing based on the practitioner who provides the service (reimbursement category 1 or 2), the type of service being provided by the practitioner such as group treatment, congregate treatment or individual treatment services, and the location of the service (i.e., natural environment or center). The use of a modifier always allows the highest possible reimbursement rate to be allowed for that EI service type. However, providers must become familiar with the chart in Appendix A in order to ensure that billing is correct for services rendered. Services that are billed inappropriately are subject to retraction during post payment reviews. A list of reimbursement codes and rates can be found in Chapter V of this manual.
Reimbursement for Assistive Technology Items:
There is no special EI coverage for assistive technology items.
Medicaid/FAMIS Plus FFS and FAMIS FFS members:
- All Assistive Technology items must have a service authorization for coverage. Service authorization for FFS enrollees is obtained through the DMAS PA contractor, KePRO. See the DMAS Durable Medical Equipment and Supplies Manual for specific instructions on how these requests should be made.
- Services not included in the Durable Medical Equipment and Supplies Manual as covered services may be requested through EPSDT for children under the age of 21. See the DMAS EPSDT Assistive Technology Manual for specific instructions on how these requests should be made. DMAS Manuals can be located on the web at: www.dmas.virginia.gov.
Medicaid/FAMIS MCO members:
- Managed Care enrollees must obtain authorization for DME services through the child’s MCO.
- Please consult with the individual’s MCO to determine the process for making these requests. A list of MCOs and contact information is available at the link below:
Reimbursement for Audiology, Physician and Dietitian Services:
There is no special EI coverage for Audiology, Physician, and Dietitian Services.
Medicaid/FAMIS Plus FFS and FAMIS FFS members:
- For information on covered services and billing for Audiology and Hearing Aid services please refer to the EPSDT Audiology and Hearing Aid Manual.
- For information on covered services performed by physicians, please refer to the Physician Manual. Dietitian services may be reimbursed under the supervision of a DMAS-enrolled physician and billed as physician services using the most appropriate Current Procedural Terminology codes.
Medicaid/FAMIS MCO members:
- While MCOs follow established DMAS policy for Audiology, Hearing Aid, Physician and Dietitian services, each MCO has different authorization requirements for these services. Please consult with the individual’s MCO to determine the process for making these requests.
The Requirements Outlined Below Shall Apply To Children Covered Under Commonwealth Coordinated Care Plus (CCC Plus) Managed Care Program
Early Intervention (EI) services, authorized through Part C of the Individuals with Disabilities Education Act (20 USC § 1431 et seq.), are covered under Commonwealth Coordinated Care (CCC) Plus MCO Contract. http://www.dmas.virginia.gov/Content_pgs/mltss-ihp.aspx
Medical necessity for the EI services shall be defined by the Member’s Early Intervention Individualized Family Service Plan (IFSP), including in terms of amount, duration, and scope. Service authorization shall not be required.
IFSP - A written plan developed by the Member’s interdisciplinary team including the MCO care coordinator and EI service team, for providing EI supports and services to eligible children and families.
The MCO shall ensure that its EI policies and procedures, including credentialing, follow Federal and State EI regulations and coverage and reimbursement rules as outlined in the DMAS Early Intervention Services and the DBHDS Manuals.
Treatment and Referrals
When a developmental delay has been identified by the provider for children under age 3, the MCO shall ensure appropriate referrals are made to the Infant and Toddler Connection and documented in the Member’s records (visit www.infantva.gov or call 804-786-3710).The MCO shall refer Members for further diagnosis and treatment or follow-up of all abnormalities uncovered or suspected. If the family requests assistance with transportation and scheduling to receive services for EI, the MCO is to provide this assistance.
Coordination with EI providers, including for children who “age-out” (age 3 and above) of the early intervention program and need services to continue. The CCC Plus care coordinator shall ensure that services are transitioned to non-early intervention providers (Physical Therapy, Occupational Therapy, Speech Language Pathology, etc.).
Early Intervention Services
The MCO shall provide coverage for EI services as defined in 12VAC30-50131, 12VAC30-50- 415, and 12VAC35-225, and within the Department’s coverage criteria and guidelines. The DMAS EI billing codes, reimbursement methodology, and coverage criteria shall be used and are described in the Department’s EI Program Manual, on the DMAS website at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal .
Early Intervention Providers
The MCO shall develop and maintain a network of EI providers, certified by Department of Behavioral Health and Developmental Services (DBHDS) with sufficient capacity to serve its CCC Plus members in need of early intervention services. Providers must be enrolled in the CCC Plus Plan. Providers of EI Care Management/Service Coordination must be certified through DBHDS as a Service Coordinator. For information about certification through DBHDS, contact Infant and Toddler Connection at 804-786-3710 or visit www.infantva.gov
Provider qualification requirements for EI are described at 12VAC30-50-131, 12VAC35-225 and in Appendix G of the DMAS Early Intervention Services Manual and the DBHDS Practice Manual.
Early intervention providers must be contracted with or have a memorandum of agreement with the local lead agency for the catchment area in which the Member resides. In order to ensure adequate early intervention provider participation, the MCO shall adhere to the Department’s early intervention coverage rules and shall comply with special payment provisions described in Section 12.4.2 of the CCC Plus contract (page 178):
1. The MCO shall ensure clean claims from EI providers are processed within fourteen (14) calendar days of receipt of the clean claim, a clean claim is defined in the CCC Plus contract, for covered services rendered to covered Members who are enrolled with the MCO at the time the service was delivered.
The MCO shall ensure EI providers are paid no less than the current Medicaid FFS rate.
EI provider agreements shall include provisions requiring the use of the DMAS established billing codes as described in the CCC Plus Coverage Chart (Section 3B).
For children with commercial insurance coverage, providers must bill the commercial insurance first for covered early intervention services except for:
- Those services federally required to be provided at public expense as is the case for
- assessment/EI evaluation,
- development or review of the Individual Family Service Plan (IFSP); and,
- targeted case management/service coordination;
- Developmental services; and,
- Any covered early intervention services where the family has declined access to their private health/medical insurance.
In following with federal regulations, the MCO shall require the EI provider complete the Notification to the Department of Medical Assistance Services: Family Declining to Bill Private Insurance form (http://infantva.org/documents/ovw-st-TaskF-Mtg-20090520Form- DecliningPriv_Ins.pdf ) and submit it with the bill to the MCO. The MCO shall keep a copy of
this form on the Member’s file for a period of ten (10) years for audit purposes. Billing codes for EI services are reflected in the CCC Plus Covered Services chart (Section 3B).