Determination of Initial Eligibility
Customize your policy alerts
Sign up for all South Carolina Department of Health and Human Services policy alerts
Know when South Carolina Department of Health and Human Services releases new policies or updates existing guidance.
Monitor payer policy activity
Governs procedures and criteria used by South Carolina IDEA/Part C Intake Coordinators to determine initial eligibility for early intervention services for children birth to three, including evaluation processes, use of informed clinical opinion, and referral/transfer workflows.
No material clinical or coverage changes in this revision.
Eligibility and Administrative Procedures
inv-01: Eligibility criteria and administrative procedures
Eligibility is established when ONE of the following pathways is met; administrative procedures for intake, referral, and transfers are described below.
Eligibility pathways
Developmental delay (state thresholds)
- Developmental delay of 40% (2 standard deviations below the mean) in one area as measured by appropriate diagnostic instruments
- Or developmental delay of 25% (1.5 standard deviations below the mean) in two areas as measured by appropriate diagnostic instruments
- Areas of development considered: Cognitive; Physical (including vision and hearing); Communication; Social or Emotional; Adaptive
Established risk condition
- Diagnosed physical or mental condition verified by a physician that has a high probability of resulting in developmental delay (examples include chromosomal abnormalities; genetic or congenital disorders; sensory impairments; inborn errors of metabolism; disorders reflecting disturbance of nervous system development; congenital infections; severe attachment disorders; complications of prematurity; disorders secondary to exposure to toxic substances, including fetal alcohol syndrome)
Use of records in lieu of evaluation
- If medical and/or other records indicate the child meets state eligibility criteria, an evaluation is not required; records must be recent (within 90 days) and with parental consent the child proceeds to the child and family assessment
Use of standardized instruments / interstate considerations
- State-approved standardized instruments must be used to determine significant developmental delays
- For children who were eligible in another state, a standardized evaluation tool or the most recent assessment less than 90 days old may be considered in the eligibility decision
Informed Clinical Opinion (ICO)
- When diagnosis or evaluation results do not meet state criteria, ICO may be used as an independent eligibility process considering all documentation, observation, and interview information
- Intake Coordinator should obtain and review all available information; if documentation supports significant delay, staff the case with supervisor and contact the state IDEA/Part C Eligibility Director if additional discussion is needed
Administrative intake, referral, and transfer procedures
- Intake Coordinator documents the multidisciplinary eligibility decision in BRIDGES and provides families with results and prior written notice
- Solicit family preferences (e.g., top 10 service coordinator choices) and notify potential service coordination agencies via joint email; transfer to the provider that responds and accepts according to agency response timelines
- Mark transfer records in OnBase and send Referral Status Update form as applicable to complete the transfer process
- Make reasonable efforts to conduct evaluation in the child’s native language and provide foreign language or sign language interpretation as appropriate
Developmental Delay Thresholds
Provider Responsibilities and Prior Authorization
Prior authorization and IFSP actions when M-CHAT/STAT indicate ASD risk
If the results of the M-CHAT Follow-up Interview and the STAT are positive for high risk of autism spectrum disorder, the Service Coordinator developing the initial IFSP must: refer the child for diagnostic evaluation, add Early Intensive Behavioral Intervention (EIBI) services to the IFSP, and request prior authorization of EIBI services from the IDEA/Part C State Office.
- Refer the child for a diagnostic ASD evaluation.
- Add Early Intensive Behavioral Intervention (EIBI) services to the initial IFSP.
- Request prior authorization of EIBI services from the IDEA/Part C State Office (follow Procedures for Development of the Initial IFSP).
Key Terms and Areas of Development
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.