Early Intensive Developmental and Behavioral Intervention (EIDBI)

Overview

Early Intensive Developmental and Behavioral Intervention (EIDBI) services offer medically necessary treatment to PrimeWest Health members under age 21 with autism spectrum disorder (ASD) or related conditions. EIDBI provides a range of individualized, intensive developmental and behavioral interventions that target the functional skills and core deficits of ASD and related conditions. EIDBI promotes optimal child independence and participation in family, school, and community life. EIDBI services educate and support families, reduce stress, and improve long-term outcomes and quality of life for children and their families.

Eligible Providers

You must do the following to provide, bill, and receive payment for EIDBI services:

1. Be an enrolled PrimeWest Health provider
2. Meet all provider qualifications on the EIDBI assurance statement for your provider type
3. Have a PrimeWest Health-approved Service Authorization (SA) to provide services for the member

Provider Enrollment

To enroll as an EIDBI provider with PrimeWest Health, complete and submit a Participation Request – Contracted Facility form. PrimeWest Health’s contracting team will contact you for any additional documents that may be needed.

Enrolling EIDBI agencies are required to indicate the DHS-approved treatment modality that they intend to provide at the agency on the EIDBI Provider Agency Assurance Statement (DHS-7120B). Refer to the Treatment modalities section of the DHS EIDBI Benefit Policy Manual for a list of DHS-approved treatment modalities.

Each EIDBI provider type has different qualifications, roles, and responsibilities during EIDBI service delivery. For more information, refer to the following:

• Comprehensive multi-disciplinary evaluation (CMDE) provider
• Qualified supervising professional (QSP)
• Level I provider
• Level II provider
• Level III provider

MHCP enrollment

Every individual provider must enroll with Minnesota Health Care Programs (MHCP) to deliver EIDBI services. Provider agencies are responsible for ensuring the following:

• Background studies are completed, and EIDBI providers are supervised until DHS issues a notice that clears the provider to provide direct contact services without supervision (per MN Stat. 245C.13, subd. 2)
• Enrollment records are accurate, updated, and maintained as needed
• Required trainings are completed and documented for all providers. For complete training requirements, refer to Individual EIDBI provider trainings.

QSP and CMDE providers are responsible for ensuring that their provider affiliation is accurate.

For enrollment information, refer to Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Enrollment Criteria and Forms.

Eligible Recipients

A child must meet all of the following criteria before being considered for EIDBI services:

1. Be a PrimeWest Health member
2. Be under age 21
3. Be medically stable and not need 24-hour medical monitoring or procedures
4. Have a diagnosis of ASD or a related condition

If all of the above are true, the child must then receive a Comprehensive Multi-Disciplinary Evaluation (CMDE) by a licensed mental health professional to determine if EIDBI services are medically necessary. Only children who meet the above criteria and receive a CMDE stating a medical necessity for EIDBI services may become eligible recipients.

Covered Services

PrimeWest Health covers the EIDBI services listed below. Only eligible provider types for each service may perform the service.

Clinical supervision

EIDBI treatment services must be delivered under the clinical supervision of a QSP.

QSPs and Level I providers with advanced certification must ensure integrity and fidelity of the services provided. They also must ensure compliance and performance standards of all supervisees to ensure services are delivered consistently with the standards of the approved modality. 

For complete clinical supervision requirements, refer to the Clinical supervision section of the DHS EIDBI Benefit Policy Manual.

Observation and Direction

PrimeWest Health requires observation and direction  authorization requests (CPT code 97155) to include individual clinical justification that demonstrates medical necessity for EIDBI services requested on or after January 1, 2026.

EIDBI providers must ensure the following:

• They meet supervision requirements in MN Stat. sec. 256B.0949, subds., 15 – 16, and that the qualified supervising professional (QSP) provides the minimum required oversight.
• Observation and direction services requested in the individual treatment plan (ITP) reflect the member’s specific clinical need. 
• They request observation and direction services in proportion to direct treatment (CPT codes 97153 and 97154) and document medical necessity in the ITP.
• They align observation and direction use with national guidance (i.e., Council of Autism Service Providers [CASP], ABA Coding Coalition), which recommends 20 percent of the person’s direct treatment hours.
• They use the ITP to explain the need for observation and direction service authorization. If observation and direction services exceed 20 percent of direct treatment hours, PrimeWest Health may request unit reductions or additional documentation. 
• They use observation and direction as a supervisory, supportive service that supplements direct treatment.

Individual Treatment Plan

An EIDBI service that covers the development of the member's initial ITP and ongoing monitoring of the member's progress. The ITP is a person-centered care plan that:

• The provider creates using the information gathered in the members comprehensive multi-disciplinary evaluation (CMDE).
• Specifies the type and amount of medically necessary services the member will receive.

Eligible Providers

The following Minnesota Health Care Programs (MHCP)-enrolled EIDBI providers can deliver and bill for ITP development and progress monitoring:

• Qualified supervising professional (QSP)
• Level I provider (under the supervision of a QSP)
• Level II provider (under the supervision of a QSP)

The QSP must complete ITP and Progress Monitoring (DHS-7109) and supervise the ITP’s implementation. Level I and II providers may provide input.

The ITP Must: 

• Specify the QSP’s name.
• Be culturally and linguistically appropriate, individualized and person-centered.
• Be based on the members diagnosis and CMDE recommendations.
• Specify the recommended medically necessary treatment and services, including the treatment modality that will be used to meet the goals and objectives.
• Include the baseline responding level and projected mastery dates.
• Include techniques that support and match the members communication mode and learning style.
• Include the frequency, intensity, location and duration of each service provided.
• Include the level of legal guardian or primary caregiver training and counseling.
• Specify any change to the physical and social environments necessary to provide EIDBI services.
• Include discharge criteria and a defined transition plan that meets the requirements outlined in EIDBI – How to complete DHS-7109 – Transition planning.
• Identify any significant changes in the members condition or family circumstances.
• Include progress monitoring updates and goal mastery data as applicable.

ITP Progress Monitoring Update

The person’s ITP progress monitoring update must include:

• Input from the person’s legal guardian or primary caregiver.
• Observation of the person performed by a qualified EIDBI provider. This may include input from licensed special education staff or other licensed health care providers.
• Documentation of the person’s current performance level on primary treatment goals and objectives, including when a goal or objective is achieved, changed or discontinued.
• Any significant change in the person’s condition or family circumstances.
• Any treatment plan modification (e.g., treatment modality, intensity, frequency, duration) and the rationale for any changes.
• Recommendation for continued treatment.

Required Form

The information above is an overview of the ITP development and progress monitoring process. The provider must use EIDBI Individual Treatment Plan (ITP) and Progress Monitoring (DHS-7109) to document the person’s initial ITP and progress monitoring updates and gather signatures for consent for the person to begin or continue receiving services. For detailed instructions, refer to EIDBI - How to complete ITP and Progress Monitoring, DHS-7109. The ITP form was updated in February 2026.

• Effective March 1, 2026: Use the updated DHS-7109 for all new or initial ITPs to avoid rejections or delayed authorizations.
• Effective Sept. 1, 2026: Use the updated DHS-7109 for all ITPs. Old forms will no longer be accepted.
   

Non-Covered Services

PrimeWest Health does not reimburse EIDBI providers for the following:

1. Services that have not been approved by the PrimeWest Health, except for services that do not require authorization
2. Services provided in the absence of required supervision
3. Services that have not been documented in the member’s health service record or in the manner required by this manual or by Minnesota Rules, part 9505.2175
4. Services provided by an unqualified person or a person for whom the provider does not have documentation showing that the person meets the required qualifications
5. Two or more services provided by the same person at the same time
6. Simultaneous services by multiple providers at the same time
7. Services provided in violation of Minnesota Rules, part 9505.0220 (the general MA excluded services provision)
8. Services that are the responsibility of a residential or program license holder, including foster care providers under the terms of an SA or administrative rules governing licensure
9. Services that include or replace academic goals and objectives that otherwise are provided through the child’s individual education plan or individual family service plan as required under the Individual with Disabilities Education Improvement Act of 2004
10. Services that are not provided in a medically supervised setting or are recreational, unless the services are primarily treatment-oriented and provided under the recipient’s ITP
11. Prevention or education programs provided to the community
12. Services that are primarily respite, custodial, or daycare
13. Services you do not provide directly to a recipient who is present, either physically or via interactive video, except for the following:
    1. Coordinated care conference
    2. Family and caregiver training and counseling
    3. ITP development
    4. Telephone calls, postal mail, or emails
    5. Observation and direction that does not include a lower-level provider
    6. Training activities that do not meet the criteria for observation and direction
    7. Activities that do not directly benefit specific EIDBI recipients
    8. Reporting, charting, and record keeping, except where this is an integral part of a CMDE or ITP development
    1. Family and caregiver training and counseling that is not provided directly to eligible recipients’ family members or significant others who are present either physically or via interactive video
    10. Observation and direction of two or more staff members at the same time
    11. Services provided by the following:
        1. A parent, legal guardian, or another person who is legally responsible for the member
        2. A person who does not meet the provider qualifications
        3. A person who has a relationship that violates ethical guidelines regarding a dual relationship (e.g., sibling, cousin, aunt/uncle, PCA worker) or would result in a conflict of interest, as defined by applicable ethical practice standards or licensure rules
    12. Recipient transportation
    13. Services that are not provided (no shows)

Access Services

EIDBI does not cover transportation and language interpreter services. Transportation may be covered through the local county or Tribal agency. Refer to the Local County or Tribal Agency NEMT Services section for more information.

Service Authorization

Overview

Some EIDBI services require Service Authorization. The authorization requirement safeguards against inappropriate and unnecessary use of health care services under State and Federal law. The maximum time span for a Service Authorization is 180 days.

Having an approved Service Authorization does not guarantee that PrimeWest Health will pay you. You must meet all other PrimeWest Health requirements to receive payment.

Authorized Services

The following services require authorization prior to delivery of service:

1. EIDBI intervention – individual, group, and higher intensity
2. Family and caregiver training and counseling
3. Intervention observation and direction

Services that Do Not Require Authorization

The following services do not require authorization prior to service delivery:

1. The annual CMDE (one per year per person without authorization)
   1. A CMDE is not required every year, but it must be performed at least once every three years or as clinically necessary
2. ITP development and monitoring
3. Coordinated care conferences
4. Travel time (reviewed retrospectively)

Request Additional Authorization of Services

Authorization Request

To request authorization for EIDBI services that exceed the service limit threshold outlined on the EIDBI billing grid (e.g., additional CMDE in a calendar year), complete and submit a Service Authorization request in the PrimeWest Health provider web portal. PrimeWest Health will not accept retroactive authorization requests for EIDBI services, with the exception of an additional CMDE within the calendar year.

Process

Providers must submit a completed CMDE and ITP for an EIDBI Service Authorization via PrimeWest Health provider web portal. The CMDE and ITP must include the following recommendations:

1. EIDBI treatment, intensity, frequency, intensity, duration, and modality
2. Level of parental involvement
3. Frequency of progress monitoring

PrimeWest Health Utilization Management reviews the CMDE and ITP to ensure and approve medical necessity for EIDBI services. Utilization Management generates a notice of authorization or denial of EIDBI services. This notice is sent to the provider and recipient.

A Service Authorization allows qualified providers to bill and receive payment from PrimeWest Health after providing EIDBI services. You are responsible for ensuring that the information in the Service Authorization is accurate when you receive the authorization notice.

Required Documentation

Submit the following information to PrimeWest Health:

1. CMDE summary
2. CMDE signature page
3. ITP summary
4. ITP signature page

The CMDE and the ITP do not need to be submitted together, but both must be received for the Service Authorization to be completed. 

Provider Responsibilities

CMDE providers must enter the CMDE summary information and the CMDE signature page.

The Initial CMDE must be completed prior to the initial ITP. The ITP and CMDE may be signed on the same day, but the ITP must not be signed prior to the CMDE being completed.

An EIDBI provider agency may submit a CMDE for medical necessity when the family or another provider gives the EIDBI provider agency a complete copy of the CMDE.

Responsibilities

PrimeWest Health will do the following within five business days of receiving the CMDE:

1. Verify that all the required components of the CMDE are present
2. Contact the CMDE provider and family if any documentation is missing

PrimeWest Health will do the following within five business days of receiving the ITP:

1. Verify all required components of the ITP are present
2. Contact the provider if any documentation is missing
3. Complete an integrated review process of the CMDE, ITP, and other PrimeWest Health-covered services the child receives
4. Determine the medical necessity of EIDBI
5. Enter information into MMIS to create a Service Authorization request
6. Generate a notice to the provider and member

Transferring Agencies

Families have the right to transfer or change EIDBI provider agencies for any reason.

New agency responsibilities

The new agency is responsible to work with the family to gather discharge information from the previous agency. When a family chooses to transfer or a provider recommends a transfer, the new agency should ask the family to sign a release of information form to gather previous records.

The new agency should review the records and determine if the person’s previous CMDE and ITP are still valid. If the CMDE and ITP are still valid, the new agency may use them for authorization. The new agency should complete a CMDE and ITP in any of the following situations:

1. The forms are no longer valid
2. The new agency cannot access the forms
3. The new agency determines it is medically necessary to complete a new evaluation and treatment plan.

If the person has already used the set number of CMDE and ITP units, the new agency may submit EIDBI Authorization Request to request authorization of additional services beyond the service limit threshold.

At the time of the authorization request, the new agency must ensure the previous agency has either:

1. Ended their service agreement or prior authorization before the requested EIDBI dates of service through the new agency
2. Provided a discharge summary that includes a discharge date and the previous agency’s signature.

If the new agency does not have the above information, PrimeWest Health will reject the request. EIDBI services can only be approved after the discharge date if PrimeWest Health determines the transition is medically necessary.

Previous agency responsibilities

The previous agency should provide the new agency with all of the following information:

1. CMDE(s)
2. ITP(s) with an updated transition plan and discharge summary
3. Any other relevant records or documentation.

The previous agency should notify PrimeWest Health and request to end the person’s Service Authorization effective on the date of discharge. This will prevent service agreement overlap and denial of authorization requests.

Transition and/or Discharge from an Agency

Although optional, PrimeWest Health recommends that the QSP complete an EIDBI Transition and/or Discharge Summary (DHS-7109A) when a transition or discharge occurs and submit it to PrimeWest Health. The DHS How to complete ITP and Progress Monitoring, DHS-7109 web page includes instructions for completing the form.

To make changes to an existing service agreement, upload the form with the requested changes to the PrimeWest Health Provider Web Portal. Be sure to adjust the units to reflect the requested changes.

Resources

• Refer to the Comprehensive multi-disciplinary evaluation (CMDE) and Individual treatment plan (ITP) development and progress monitoring sections of the DHS EIDBI Benefit Policy Manual for instructions on how to complete the CMDE and ITP forms.
• Refer to the Early Intensive Developmental and Behavioral Intervention (EIDBI) Compliance and Program Integrity Guide (DHS-8632) for important links to training and tools to support compliance with EIDBI program standards. Review this document to ensure your agency is aligned with current expectations and best practices.

Billing

Refer to the EIDBI Billing Grid for service names, procedure codes, modifiers, units, and service limits. Refer to the MHCP Fee Schedule for the most current rate information.

Note: All claims submitted for any services delivered by a Level III provider are required to have the UMPI number of the rendering provider.

The following instructions must be followed when submitting claims for EIDBI services:

1. Use the Professional (837P) claim.
2. Bill only for services already provided.
3. CMDE services must be provided within 30 business days, and up to 5 units. If services are provided in two different months, separate claims should be submitted for each month.
4. A claim submission must include the following:
   1. The pay-to provider
   2. The procedure code for the service provided
   3. The appropriate modifier(s)
   4. The UMPI or NPI of the rendering provider who delivered the service (except for any services delivered by a Level III provider)
   5. The supervising provider for any services that require the supervision of a QSP
5. Bill only for services approved on the Service Authorization.
6. Do not bill services that require a Service Authorization on the same claim as services that do not require a Service Authorization.
7. Do not exceed 9 hours a day for any individual or group intervention units.
8. Submit your usual and customary charges for the service.
9. Enter diagnosis codes when submitting claims for all EIDBI services.
10. Use the most current, most specific diagnosis code.
11. PrimeWest Health will display the recipient’s diagnosis code on the Service Authorization letter.
12. Use information from your Service Authorization, such as the following:
    1. The PrimeWest Health-enrolled provider who is authorized to provide EIDBI services
    2. The rate of payment for the service
    3. The number of units approved
    4. The date span of authorization
    5. The approved procedure code(s)
    6. Use date spans only when you have provided services for all dates in the span
    7. Tribal providers should refer to the Tribal and Federal Indian Health Services manual page
13. Use the following place of service codes as applicable: 
    1. 12 (home and community) – EIDBI services provided in a community setting, as outlined in the person’s Individual Treatment Plan
    2. 11 (office) – EIDBI services provided in a location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local Public Health clinic, or intermediate care facility (ICF) where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
    3. For non-direct EIDBI services, such as treatment planning and review or progress monitoring without the member or caregiver present, providers should use place of service 11 (office) to indicate the provider’s business location, including a home office.

PrimeWest Health accepts claims for CMDE services rendered by a CMDE clinical trainee.

Effective January 1, 2026, EIDBI providers must not deliver or bill for the following direct intervention services during homeschool or online (virtual) school instruction:

• 1:1 services (billing code 97153)
• Group services (billing code 97154)
• High-intensity intervention with the person (billing code 0373T).

This change ensures EIDBI services do not replace or interfere with the student’s educational program and maintains clear boundaries between EIDBI and educational services.

Covered services include clinically necessary family or caregiver training (billing code 97156) during homeschool or online (virtual) instruction if the parent or caregiver is present and participates.

Midpoint Billing

Providers may bill EIDBI services only when medically necessary services are being actively delivered by a provider who is present and engaged with the member served and targeting goals outlined in the member’s individualized treatment plan. You must pause billing whenever service delivery stops, including during provider breaks such as restroom use, meals or snacks, phone calls, administrative tasks, or stepping away from the session for any reason.

Midpoint billing for EIDBI services follows the Centers for Medicare and Medicaid Services rules and allows a unit to be billed when more than half of the unit’s required service time (for example, 8 minutes or more for a 15-minute unit) has been provided during continuous service delivery. Midpoint billing applies only when services remain uninterrupted, and the provider is actively engaged in intervention activities during brief treatment-related pauses. PrimeWest Health may recoup payments or take other program integrity actions if you bill any time you are not actively delivering services

Billing when a Member has Primary Commercial Insurance

EIDBI providers are not required to bill a member’s commercial insurance before billing Medical Assistance (Medicaid). PrimeWest Health will seek reimbursement from third parties whenever claims have been paid for which there is third party liability.

Telehealth

Certain EIDBI services are eligible to be provided via telehealth. Services provided via telehealth have the same service thresholds, reimbursement rates, and authorization requirements as services delivered in-person. Bill for services delivered via telehealth with place of service 02. PrimeWest Health does not reimburse for connection charges, origination, set-up, or site fees.

Modifier 93 is required when synchronous telehealth rendered via telephone or other real-time telecommunications system is used.

For more information about delivering EIDBI services via telehealth, review the EIDBI telehealth services section of the DHS EIDBI Policy Manual.

For more information on PrimeWest Health telehealth billing, see the Telehealth Services section of the PrimeWest Health Provider Manual.

Updated_05/26/2026