* For full MNC, refer to:
www.mass.gov/eohhs/gov/commissions-and-initiatives/cbhi/home-and-community-based-behavioral-health-srvcs.html
Version 2/17/16
Evaluation of need for ICC
Families with children under 21 in outpatient should be periodically reevaluated regarding their need
for Intensive Care Coordination. In order to ensure that this occurs, all MCEs require documentation
within 30 days of the first visit and every six months thereafter
using this form if the youth has SED
Member information
Name: ________________________________________
DOB: ________________________
MassHealth ID: ________________________
Evaluation information
Date: ________________________
Does youth meet MNC for ICC? YES NO*
*if youth doesn’t meet MNC no parental signature required
If yes, has ICC been discussed CURRENTLY with family?
YES NO
If NO to discussion, why not?
If YES, what is the outcome of the discussion? Referral made Referral NOT made
Parent / guardian signature
Abbreviated medical
necessity for ICC*:
Youth must meet criteria for SED,
and must have MassHealth
Standard or CommonHealth, and
{ a. need or receive
multiple services other than ICC
from the same or multiple
provider(s)
or
b. need or receive
services from, state agencies,
special education, or a
combination thereof }
and
c. need a care planning
team to coordinate services the
youth needs from multiple
providers or state agencies,
special education, or a
combination thereof.
