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Serious Emotional Disturbance (SED) Determination Guidelines (State of Idaho membership only)

Subject Serious Emotional Disturbance (SED) Determination

Next Review 12/2010

Description

Serious Emotional Disturbance = SED. This group is defined as 17 & younger. This designation needs to be reviewed at least annually for diagnosis, functional status review and age verification. This designation allows the member to receive the extended mental health substance abuse benefit.

Policy

A designation of SED is based on the CALOCUS Function Assessment tool as defined by the House Bill 615 as the basis for SED. The HB language reads: as “an emotional or behavioral disorder, or a neuro-psychiatric condition which results in a serious disability, and which requires sustained treatment interventions, and causes the child's functioning to be impaired in thought, perception, affect or behavior. A disorder shall be considered to ’result in a serious disability if it causes substantial impairment of functioning in family, school or community. A substance abuse disorder does not, by itself, constitute a serious emotional disturbance, although it may coexist with serious emotional disturbance.”

The presenting member must meet the reasonable expectation that the serious emotional disturbance will respond to treatment.

The level of functioning must be made by the member having a diagnosable mental, behavioral, emotional DSM-IV disorder with evidence of functional impairment and is not due to substance abuse or developmental disorders.

The designation will be made in conjunction with the appropriate documentation and with appropriate providers, meeting the Blue Cross of Idaho licensure requirements.

When the diagnostic record is received, the Case Manager will make the SED designation. It may be necessary to consult with the Medical director or other providers to make this designation. When an SED designation is made, the Case Manager will update or have the MMSS update the file in Facets & CCA as necessary. The member and provider(s) will be notified either verbally/in writing of the SED designation.

References:

  1. Kenneth Minkoff, MD. 'CCISC MODEL - COMPREHENSIVE, CONTINUOUS, INTEGRATED SYSTEM OF CARE MODEL'
  2. Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Rev (2005)
  3. CALOCUS; Version 1.5

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