• A written referral from the patient’s primary care physician (PCP) dated within 12 months from the date of services requesting an evaluation for EIDT services.
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  • A prescription dated within 12 months from the date of service, signed and dated by the physician for each service identified as needed by the patient
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  • Copy of the results of the developmental screen by DHS vendor or waiver of the screen (letter from Optum). 
  • For children enrolled prior to 8/1/2018, a letter from Optum is not required.
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  • A copy of the completed developmental evaluation and/or any other evaluations that determine eligibility for services.
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  • An Individual Treatment Plan (ITP) dated within 12 months from the date of service that was developed by and signed by Early Child Development Specialist. 
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  • For the specific time frame of the claim being reviewed, a description of specific EIDT service(s) provided with
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    • The date and actual time service(s) were rendered
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    • The name(s) and title(s) of the individual providing the service(s) The relationship of the service to the goals and objectives in the ITP.
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  • Weekly progress notes signed or initialed by the person providing services, including a description of the beneficiary’s status with respect to his or her goals and objectives
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  • If the patient is no longer receiving services, copy of discharge notes and a summary are required.