Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyDHA ECHO Intellectual Disability Coverage | OpenPa…
    Ask Trek AI about this page
    CurrentDHAPolicy 6010.63-M

    ECHO Eligibility for Intellectual Disability

    Customize your policy alerts

    Sign up for DHA Policy 6010.63-M alerts

    Get alerted when Policy 6010.63-M changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy section governs eligibility for the Extended Care Health Option (ECHO) when intellectual disability is the qualifying condition.

    Policy Summary
    PayerDHA
    PolicyECHO Eligibility for Intellectual Disability
    Policy CodePolicy 6010.63-M
    Change TypeNo material change
    Effective DateSep 1, 2005
    Next Review DateN/A
    Key ActionDocument a diagnosis of moderate or severe intellectual disability established in accordance with the current DSM criteria.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    9Chapter
    2.2Section
    Moderate or severeQualifying severity
    < 3 yearsAge threshold
    4Presumptive conditions
    2Excluded categories

    ECHO Eligibility Criteria

    DSM-based intellectual disability

    An ECHO qualifying condition is established when the beneficiary has a qualifying diagnosis meeting the applicable DSM criteria.

    Moderate or severe intellectual disability diagnosis: The beneficiary has a diagnosis of moderate or severe intellectual disability.Moderate or severe

    The diagnosis must be established in accordance with the criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.

    Presumptive conditions before age three

    For a beneficiary less than three years of age, any one of the following conditions may be presumed to precede a diagnosis of moderate or severe intellectual disability.

    ONE of the following presumptive conditions

    • Rett's syndrome is present.
    Policy Summary
    PayerDHA
    PolicyECHO Eligibility for Intellectual Disability
    Policy CodePolicy 6010.63-M
    Change TypeNo material change
    Effective DateSep 1, 2005
    Next Review DateN/A
    Key ActionDocument a diagnosis of moderate or severe intellectual disability established in accordance with the current DSM criteria.
    SourceLink
    On This Page
    ECHO Eligibility CriteriaDiagnostic Coding and ThresholdsDocumentation and Denial RisksPolicy ContextKey Definitions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ICD-9-CM 330.8 or ICD-10-CM F84.2.

  1. Down syndrome is present.

    ICD-9-CM 758.0 or ICD-10-CM Q90.0-Q90.9.

  2. Fragile X syndrome is present.

    ICD-9-CM 759.83 or ICD-10-CM Q99.2.

  3. Fetal alcohol syndrome is present.

    ICD-9-CM 760.71 or ICD-10-CM Q86.0.

    4. Developmental delay before age three

    For a beneficiary less than three years of age, developmental delay qualifies as moderate or severe intellectual disability when the testing requirement is met.

    Developmental delay qualification: The beneficiary is less than three years of age, and standardized diagnostic psychometric tests demonstrate developmental delay in adaptive, cognitive, or language function.Equivalent to two standard deviations below the mean

    Testing must be standardized diagnostic psychometric testing.

    Attention-Deficit and Disruptive Behavior Disorders are not qualifying conditions for ECHO eligibility unless the beneficiary younger than three years meets the developmental-delay requirements.

    Learning disorders, whether considered individually or collectively, are not qualifying conditions for ECHO eligibility.

    Diagnostic Coding and Thresholds

    Rett's syndromemixed
    330.8Rett's syndrome (ICD-9-CM)
    F84.2Rett's syndrome (ICD-10-CM)
    Down syndromemixed
    758.0Down syndrome (ICD-9-CM)
    Q90.0-Q90.9Down syndrome (ICD-10-CM)
    Fragile X syndromemixed
    759.83Fragile X syndrome (ICD-9-CM)
    Q99.2Fragile X syndrome (ICD-10-CM)
    Fetal alcohol syndromemixed
    760.71Fetal alcohol syndrome (ICD-9-CM)
    Q86.0Fetal alcohol syndrome (ICD-10-CM)
    Developmental Delay Psychometric Threshold
    Testing methodStandardized diagnostic psychometric tests
    Required thresholdEquivalent to two standard deviations below the mean
    Applicable functionsAdaptive, cognitive, or language function
    Age for Presumptive Conditions or Developmental-Delay Pathway
    Age requirementLess than three years of age
    Applicable pathwayPresumptive conditions or developmental delay
    Presumptive diagnosisMay precede a diagnosis of moderate or severe intellectual disability

    Documentation and Denial Risks

    Documentation Required

    DSM-Conforming Intellectual Disability Diagnosis

    Document a diagnosis of moderate or severe intellectual disability established in accordance with the criteria in the current edition of the DSM published by the American Psychiatric Association.

    Documentation Required

    Standardized Testing Required Before Age Three

    For beneficiaries younger than three years, provide standardized diagnostic psychometric test results demonstrating developmental delay equivalent to two standard deviations below the mean in adaptive, cognitive, or language function.

    Documentation Required

    Document Applicable Presumptive Condition

    For beneficiaries younger than three years, document an applicable presumptive condition that may precede a diagnosis of moderate or severe intellectual disability.

    • Rett syndrome: ICD-9-CM 330.8; ICD-10-CM F84.2
    • Down syndrome: ICD-9-CM 758.0; ICD-10-CM Q90.0–Q90.9
    • Fragile X syndrome: ICD-9-CM 759.83; ICD-10-CM Q99.2
    • Fetal alcohol syndrome: ICD-9-CM 760.71; ICD-10-CM Q86.0
    Denial Risk

    Diagnosis Does Not Meet DSM Severity Criteria

    Coverage may be denied when the diagnosis is not moderate or severe intellectual disability or does not conform to the criteria in the current DSM. Document the qualifying severity and DSM-conforming diagnosis.

    Denial Risk

    Insufficient Developmental-Delay Testing

    Before age three, the developmental-delay pathway requires standardized diagnostic psychometric testing demonstrating delay equivalent to two standard deviations below the mean in adaptive, cognitive, or language function.

    • Testing results must identify the affected functional domain: adaptive, cognitive, or language.
    • Without the required standardized testing results, developmental delay does not qualify as moderate or severe intellectual disability under this pathway.
    Denial Risk

    Attention-Deficit or Disruptive Behavior Disorder Excluded

    Attention-deficit and disruptive behavior disorders are not qualifying ECHO conditions unless the developmental-delay requirements are satisfied.

    Denial Risk

    Learning Disorder Alone Does Not Qualify

    Learning disorders, individually and collectively, are not qualifying conditions for ECHO eligibility.

    Policy Context

    The policy recognizes moderate or severe intellectual disability, diagnosed under the criteria in the current edition of the DSM published by the American Psychiatric Association, as an ECHO qualifying condition. For beneficiaries younger than three years, certain listed genetic or congenital conditions may be presumed to precede such a diagnosis, and developmental delay may qualify when standardized diagnostic psychometric testing demonstrates delay equivalent to two standard deviations below the mean in adaptive, cognitive, or language function.

    Key Definitions

    Intellectual Disability
    Qualifying diagnosisModerate or severe intellectual disability
    Diagnostic standardCriteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)
    Publishing authorityAmerican Psychiatric Association
    Qualifying Developmental Delay
    Age requirementBeneficiary younger than three years
    Testing requirementStandardized diagnostic psychometric tests must demonstrate the delay
    Qualifying thresholdEquivalent to two standard deviations below the mean
    Applicable functionsAdaptive, cognitive, or language function