CurrentSouth Carolina Department of Health and Human ServicesPolicy N/A
Early Intervention Services In Natural Environments
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Defines requirements and procedures for providing IDEA/Part C early intervention services in natural environments, responsibilities of Service Coordinators and providers, exceptions, and specific service rules (e.g., audiology, EIBI) applicable to South Carolina's BabyNet program.
Policy Summary
PayerSouth Carolina Department of Health and Human Services
PolicyEarly Intervention Services In Natural Environments
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateSep 1, 2023
Last ReviewSep 1, 2023
Next Review DateSep 1, 2023
Key ActionEnter required EIBI evaluation and planned services data in BRIDGES and email BabyNet@scdhhs.gov with the child's BRIDGES ID to request prior authorization.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
6service setting options displayed in BRIDGES
32/yr97151 limit
160/wk97153 limit
64/mo97155 limit
48/yr97156 limit
Caregiver presentcaregiver requirement
Coverage for Early Intervention Services in Natural Environments
Coverage criteria for natural environments and specific services
Coverage is provided for IDEA/Part C services in natural environments with listed exceptions and procedure-specific rules; some services require prior authorization, documentation in BRIDGES, and have defined unit limits.
IFSP services must be provided in natural environments (home and community routines, activities, and settings in which children without disabilities would typically participate). Services delivered in natural environments focus on training parents and family members and are provided as part of family routines. A service may be provided outside a natural environment only if satisfactory progress cannot be achieved in the natural environment and the IFSP team documents justification.
Documentation for non-natural environment: If the IFSP team elects a non-natural environment due to lack of satisfactory progress, the Service Coordinator and IFSP team must: provide data and documentation of concerns regarding the child's progress in family routines; provide a justification for services outside the natural environment on the Planned Services screen in BRIDGES including steps to return the child to the natural environment; and review the justification within six months at the next periodic or annual IFSP review.
Automatic exceptions to natural environment requirement
- Fitting of assistive technology devices (exempt)
- Audiological services (exempt; see audiology rules)
- Medical services provided by a licensed physician for diagnostic or evaluation purposes and ophthalmology/optometry services necessary for habilitation/rehabilitation of visual disorders (exempt)
- Intake coordination and service coordination (exempt)
- Activities related to initial eligibility and development/delivery of IFSP services prior to NICU discharge (exempt)
Provider responsibilities when changing service setting: EIS providers must not change service location from natural to non-natural without an IFSP Change Review; concerns about progress must be reported to the Service Coordinator so an IFSP Change Review can be held. Changing setting without an IFSP Change Review may result in recoupment of provider reimbursement, termination of the provider agreement, or both. If no EIS providers are available locally, the Service Coordinator may temporarily utilize non-natural environment providers, but must call an IFSP Change Review when a natural-environment provider becomes available; if the parent chooses a non-natural provider when a natural-environment provider is available, the family is responsible for all costs and the Service Coordinator must document the change in BRIDGES.
Audiology coverage rules
- Audiological evaluation consists of a hearing screening and, if indicated, a comprehensive diagnostic evaluation; the entire AE may be completed in one appointment or across appointments.
- IDEA/Part C will pay for one screening (if the child passes) OR one comprehensive audiological diagnostic evaluation (if the child fails screening). Routine follow-up visits to monitor at-risk children are not covered unless the IFSP team documents the need and incorporates them into the IFSP.
- Proof of manufacturer's invoice price is required prior to IDEA/Part C reimbursement for hearing aids; IDEA/Part C will not cost share hearing aid prices beyond established IDEA/Part C rates. Cochlear implant costs and costs directly related to implant use/maintenance/training are not covered. SCDHEC Hearing Program may provide hearing aids for eligible children under income/Medicaid criteria.
EIBI prior authorization and documentation: Early Intensive Behavioral Intervention (EIBI) evaluations, screenings, and planned services data must be entered in BRIDGES per program instructions (including ASD diagnosis code F84.0 where applicable). For prior authorization of EIBI, required information must be entered in BRIDGES and the Service Coordinator must email BabyNet@scdhhs.gov with the child's BRIDGES ID and request for prior authorization. Program Consultants (or designee) will document and bill autism services in BRIDGES; paraprofessional services must be summarized and documented weekly.
EIBI CPT codes and unit limits: EIBI services use specified CPT codes and unit limits: 97151 (Behavior identification assessment): 32 units per year (15-minute units); 97153 (Adaptive treatment behavior by protocol/'line therapy'): 160 units per week (15-minute units); 97155 (Adaptive behavior treatment with protocol modification): 64 units per month (15-minute units); 97156 (Family adaptive behavior treatment guidance): 48 units per year (15-minute units). Providers must be enrolled in BRIDGES and have valid Medicaid and IDEA/Part C provider agreements to receive payment.
Billing and payment conditions: Payment will only be made to EIBI providers with valid Medicaid and IDEA/Part C provider agreements and BRIDGES enrollment. All reimbursement is paid directly to the provider, who is responsible for payment to paraprofessional staff as appropriate.
Health services exclusions under IDEA/Part C: Health Services under IDEA/Part C do not include consultations by physicians unfamiliar with the child and their IFSP, medical diagnostic evaluation of unknown conditions, surgical services, services purely medical in nature (e.g., hospitalization, prescribing medications), devices necessary to control or treat a medical condition, and routine medical-health services (e.g., immunizations, well-baby care).
Caregiver presence and documentation for therapy sessions: Occupational, physical, and speech-language therapy must be provided with the parent or primary caregiver present and actively involved for the entire session. Therapists must document adaptations, interventions, and ongoing consultation/training to family/caregivers and other team members in the child's progress notes.
Referral for nutrition services: Children in need of nutrition services should be referred to DHEC Family Support Services (FSS).
Reporting requirement: Service settings for each service must be reported annually to the U.S. Department of Education (OSEP) via BRIDGES with the setting identified for federal reporting.
Cost sharing and family choice: IDEA/Part C will not cost share hearing aid prices beyond established IDEA/Part C rates. If a parent opts to use a non-natural environment provider when a natural-environment provider is available, the family is responsible for all associated costs.
Service Coordinator duties when authorizing services: The Service Coordinator must ensure Part C dollars are used only as payor of last resort, that referrals for IDEA/Part C services are made only to qualified personnel, and that services being authorized are listed on the IFSP.
IDEA/Part C Coverage Criteria and Limitations
Coverage stance and limitations for IDEA/Part C early intervention services in natural environments.
Medical and Surgical Exclusions: Consultation by physicians unfamiliar with the child and their IFSP, medical diagnostic evaluation of unknown conditions, surgical services, services purely medical in nature (e.g., hospitalization, prescribing medications), devices to control or treat a medical condition, and routine medical-health services (e.g., immunizations, well-baby care) are not included under Health Services IDEA/Part C.
Nutrition Services Referral: Children in need of nutrition services should be referred to DHEC Family Support Services (FSS).
Therapy Session Requirements: Occupational, physical, and speech-language therapy must be provided with the parent or other primary caregiver present and actively involved for the entire session. Therapists must document adaptations and interventions provided to the family/caregiver to support the child's participation in home and community activities, and ongoing consultation/training to family members, caregivers, and other team members must be recorded in the child's progress notes.
Direct Service Restrictions: Services must be provided as established on the IFSP and scheduled with the parent/caregiver; direct service should never be provided without consultation to family members, caregivers, and other team members. Acute medically based rehabilitative therapy for recent injuries (e.g., fractured leg, car accident, orthopedic surgery) is a medically based service outside IDEA/Part C.
Service Coordinator Responsibilities: The Service Coordinator is responsible for ensuring Part C dollars are used only as payor of last resort, referrals for IDEA/Part C services are made only to qualified personnel, and that services being authorized are listed on the IFSP.
CPT Codes, Limits, and Coding Rules
No codes specified in this sectionmixed
| No codes listed |
inv-05: 97151 unit limit
Code97151
ServiceBehavior identification assessment (ABA)
Unit limit32 units per year (15-minute units)
BRIDGES entryEntered as 1 time semiannually for 8 hours; can only be authorized one time per year.
inv-06: 97153 unit limit
Code97153
ServiceLine therapy: Adaptive Treatment Behavior by Protocol
Unit limit160 units per week (15-minute units)
BRIDGES entryEntered as one time per month for 160 hours.
inv-07: 97155 unit limit
Code97155
ServiceAdaptive Behavior Treatment with Protocol Modification
Unit limit64 units per month (15-minute units)
BRIDGES entryEntered as 1 time per month for 16 hours.
inv-08: 97156 unit limit
Code97156
ServiceFamily Training Family Adaptive Behavior Treatment Guidance
Unit limit48 units per year (15-minute units)
BRIDGES entryEntered as 1 time semiannually for 6 hours.
inv-09: No coding thresholds specified
ScopeNo specific CPT codes or unit thresholds are specified in this section.
Related noteRefer to specific service sections for coded services (e.g., EIBI codes listed elsewhere).
StatusNeutral — no thresholds provided in this part of the document.
Provider Responsibilities and Prior Authorization
Prior Authorization
EIBI prior authorization procedure
Enter the required EIBI evaluation, screening, and planned services information into BRIDGES, then have the Service Coordinator email BabyNet@scdhhs.gov with the child's BRIDGES ID and a statement requesting prior authorization for initiation of EIBI services.
- Required EIBI data must be entered into BRIDGES before emailing for authorization
- Email must include the child's BRIDGES ID and an explicit request for prior authorization
Documentation Required
Service Coordinator authorization responsibilities
When authorizing services on the IFSP, the Service Coordinator must ensure Part C funds are used as the payor of last resort, referrals are made only to qualified personnel, and that all services authorized appear on the IFSP.
- Verify other payors have been pursued before using Part C funds
- Confirm referred providers meet qualification requirements
- Ensure every authorized service is documented on the IFSP
Key Definitions and Roles
inv-12: Natural Environments
DefinitionNatural environments are home and community routines, activities, and settings in which children without disabilities would typically participate.
Service focusWhen services are provided in natural environments, they focus on training parents and are provided as part of a family's typical routines and activities.
RestrictionServices may occur outside natural environments only if early intervention cannot be achieved satisfactorily in a natural environment and the IFSP team documents justification.
inv-13: Exceptions to Natural Environments
Automatic exceptionsFitting of assistive technology devices; audiological services; specified medical services by licensed physicians, ophthalmologists, or optometrists; intake coordination; service coordination; activities related to initial eligibility; IFSP services prior to NICU discharge.
Short-term non-natural optionIFSP team may choose a non-natural environment on a short-term basis if parent and team agree child is not making satisfactory progress; requires data, documentation, and BRIDGES justification with a plan to return to natural environment.
Review requirementJustification must be reviewed within six months at the next periodic or annual IFSP review.
inv-14: Service Coordinator is the individual responsible for ensuring payor of last resort, qualified referrals, and that services authorized appear on the IFSP; therapists must provide caregiver-inclusive services and document family adaptations and training.
Service Coordinator responsibilitiesEnsure Part C dollars are used only as payor of last resort; ensure referrals are made only to qualified personnel; ensure services authorized are listed on the IFSP.
Therapist requirementOccupational, physical, and speech-language therapy must be provided with the parent or primary caregiver present and actively involved for the entire session; therapists must document adaptations and interventions provided to family/caregiver.
DocumentationOngoing consultation/training to family members, caregivers, and other team members must be documented in the child's progress notes by the therapist.
Policy Summary
PayerSouth Carolina Department of Health and Human Services
PolicyEarly Intervention Services In Natural Environments
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateSep 1, 2023
Last ReviewSep 1, 2023
Next Review DateSep 1, 2023
Key ActionEnter required EIBI evaluation and planned services data in BRIDGES and email BabyNet@scdhhs.gov with the child's BRIDGES ID to request prior authorization.
SourceLink
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