Medica’s Minnesota Health Care Programs products administer behavioral health, including EIDBI, through Optum: DHS’s grid sends Medica network questions to Optum Provider Services and providerexpress.com, and Optum’s Minnesota page carries the DHS CMDE and ITP forms under "Medicaid Early Intensive Developmental and Behavioral Intervention (EIDBI)." Since October 1, 2026 Medica also runs the former UCare Medical Assistance plans as Medica One Health Plan, which has its own guide.
Per DHS’s October 2026 grid, Medica requires no referral ("No referral required. Some services require authorization"), takes EIDBI authorization requests by fax to Medica Behavioral Health at 855-454-8155 ("Fax ITP and CMDE requests"), requires authorization of all services for noncontracted providers, and handles network participation through Optum Provider Services (877-614-0484, providerexpress.com). Optum’s quick reference guide for Medica Behavioral Health lists Provider Services at 800-848-8327 for benefits, claims, billing and prior authorization, and EDI payer ID 87726. Medica publishes no EIDBI medical policy of its own that we could find; Optum’s commercial ABA criteria do not govern Medical Assistance, where the EIDBI statute and DHS manual set the benefit.[1][3][2]
Every Medical Assistance plan must deliver EIDBI as § 256B.0949 defines it: under 21, CMDE first, an ITP supervised by a QSP, at least one hour of clinical supervision per 16 hours of direct treatment, monthly QSP observation and direction, and documentation entered within 72 hours. DHS’s manual requires MCOs to credential Level I, II, III and QSP providers from DHS enrollment data within 45 days of a clean application. Since January 1, 2026 the Minnesota Utilization Review Act’s five-business-day standard applies to Medical Assistance managed care.[4][5][6][7][8]
The questions that decide whether a family can start with Medica — Minnesota Health Care Programs, and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. The statute defines the covered "person" as "an individual under 21 years of age" (§ 256B.0949, subd. 2(q)), and DHS lists "Younger than age 21" among the eligibility criteria.[4][15]
Medica publishes no rule of its own. No expiry on the diagnosis itself; the clock is the CMDE. DHS says the CMDE "must be completed to initiate services and updated at least once every three years" (or sooner when the condition, diagnosis, family, placement or setting changes), the CMDE provider must complete the direct observation within 60 days of the CMDE date, and to restart services after termination "If the person’s CMDE is more than 36 months old … the person must receive a new CMDE." The annual CMDE for reauthorization is due 30 to 60 days before the current service authorization ends.[16][17]
Set by statute: the diagnosis of ASD or a related condition must be "completed by either (i) a licensed physician, advanced practice registered nurse, or physician assistant, or (ii) a mental health professional," be based on current DSM criteria with direct observation and caregiver information, and meet the standard diagnostic assessment rules of § 245I.10, subd. 6 (§ 256B.0949, subd. 4). DHS’s eligibility page says assessors use the DC:0-5 for children five and younger and the DSM from age six. The CMDE provider (physician, APRN, PA, mental health professional, or qualified clinical trainee with 2,000 hours of ASD experience or equivalent coursework) then confirms medical necessity.[4][15]
No instrument is mandated for EIDBI itself: DHS "strongly encourages providers to use standardized assessment tools" but "does not require specific assessment tools." The exception is a CMDE submitted for other disability or benefit decisions (waiver enrollment, SSI): there DHS requires "A direct observational assessment (e.g., ADOS-2)" and "A structured caregiver interview (e.g., ADI-R)," and says developmental history or non-autism-specific screens alone are "insufficient."[15][16]
No. DHS’s October 2026 grid, for Medica: "No referral required. Some services require authorization."[1]
Medica publishes no EIDBI telehealth rule of its own. Yes, for most EIDBI services. The statute says Medical Assistance "covers medically necessary EIDBI services and consultations delivered via telehealth … in the same manner as if the service or consultation was delivered in person" (§ 256B.0949, subd. 13(l)). DHS lists the CMDE (97151), coordinated care conference, family/caregiver training (97156/97157), ITP development and progress monitoring (H0032), individual and group intervention (97153/97154) and observation and direction (97155) as telehealth-eligible; higher-intensity intervention (0373T) "cannot occur via telehealth." Same thresholds, authorization and rates as in person; QSP observation and direction may be remote for at most two consecutive months. Bill POS 02 (not at home) or POS 10 (at home), modifier 93 for audio-only, and never use telehealth POS or modifiers for non-client-facing services. Providers enroll for telehealth on the Telehealth Provider Assurance Statement (DHS-6806).[4][18][19]
Medica publishes no EIDBI decision clock. State and federal law apply: since January 1, 2026 standard determinations are due within five business days of a complete request and expedited ones within 48 hours (§§ 62M.01, subd. 3(b), 62M.05), inside the federal 7-calendar-day ceiling (42 CFR 438.210(d)).[7][8][9]
Medical Assistance is still the payer of last resort, but EIDBI is "pay and chase." DHS: "EIDBI providers are not required to bill a member’s commercial insurance before billing Medicaid. MHCP or the MCO will seek reimbursement from third parties … This ‘pay and chase’ process applies to both fee-for-service and managed care members," though a payment received from another source must still be reported. That matches the federal rule letting states pay EPSDT claims and recover later (42 CFR 433.139(b)(3)(i)). For authorization, DHS tells providers with privately insured members to "follow the primary insurance’s authorization procedures."[6][10]
Coverage decides whether Medica — Minnesota Health Care Programs pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Medica publishes no EIDBI supervision rule of its own. Set by statute for every Medical Assistance member, fee-for-service or managed care. An EIDBI agency must "provide clinical supervision for a minimum of one hour for every 16 hours of direct treatment per person, unless otherwise authorized in the person’s individual treatment plan," and must provide "the required EIDBI intervention observation and direction by a QSP at least once per month" (Minn. Stat. § 256B.0949, subd. 16(a)(15)–(16), as amended by Laws 2026, ch. 95). The QSP may do that monthly observation and direction by telehealth for no more than two consecutive months; the third month must be in person. DHS’s clinical supervision page (updated 9/15/26) adds that each person gets one primary QSP (who signs the ITP), a backup QSP must be available, and a different ratio needs an exception documented in the ITP and approved through service authorization. Every intervention must be "provided by a qualified EIDBI provider and supervised by a QSP" (subd. 13(a)).[4][5][13]
Medica publishes no EIDBI note rule of its own. Statutory since 2026. New subdivision 19 of § 256B.0949 (Laws 2026, ch. 95, art. 4, sec. 26) requires all CMDE and EIDBI documentation to be "signed and dated by the provider completing the documentation with the provider’s full name, title, and credentials," to "be entered within 72 hours of service and contain a record and explanation of any delays in entry," and to "include a record of supervision and oversight for staff providing services requiring supervision." "Each EIDBI service occurrence must be documented in a progress note." DHS-7108 (CMDE) must be signed by the CMDE provider and the caregiver or guardian, and DHS-7109 (ITP) by the QSP and the caregiver or guardian; those signatures are the family’s consent to start or continue services.[5][14]
Not published by Medica or Optum for EIDBI.[2]
Ask the plan: Medica Behavioral Health Provider Services, 800-848-8327: ask whether 97153 and 97155 by different staff may be billed for the same time.
Not published by Medica or Optum for EIDBI.[2]
Ask the plan: Medica Behavioral Health Provider Services, 800-848-8327: ask whether DHS’s billing-grid limits apply.
Not published by Medica or Optum for EIDBI.[2]
Ask the plan: Medica Behavioral Health Provider Services, 800-848-8327: confirm EIDBI POS codes.
Not published by Medica or Optum for EIDBI.[2]
Ask the plan: Medica Behavioral Health Provider Services, 800-848-8327: ask whether the rendering provider and supervising QSP must both be on the claim.
Optum, as Medica Behavioral Health. Fax the CMDE and ITP to 855-454-8155; Provider Services is 800-848-8327.
Both are Medica. Medica One Health Plan is the former UCare Medical Assistance business, which moved to Medica on October 1, 2026; DHS’s grid lists it separately with the same Optum contacts.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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