---
title: "PrimeWest Health ABA / EIDBI coverage: the intake guide."
url: "https://carelu.com/payers/primewest-health-minnesota"
markdown_url: "https://carelu.com/payers/primewest-health-minnesota.md"
state: MN (Minnesota)
payer: PrimeWest Health
kind: Medicaid managed care plan (MCO)
parent_program: Minnesota Medical Assistance (EIDBI benefit, managed care)
description: "How PrimeWest Health covers ABA under the EIDBI benefit: which services need authorization, its 20% observation-and-direction rule, no retroactive authorizations, claim and telehealth rules, 180-day filing, and what intake should collect."
last_reviewed: October 2026
---

# PrimeWest Health ABA / EIDBI coverage: the intake guide.

_Payer Guide · PrimeWest Health · Minnesota · Last updated October 2026 · 9 primary sources_

> Medical Assistance plan with a full EIDBI manual chapter: portal authorization, no retro auths, O&D near 20%, POS 02 telehealth.

PrimeWest Health is one of the eight Medical Assistance plans on DHS’s October 2026 EIDBI grid. Its provider manual has a complete EIDBI chapter (updated September 4, 2026) that tracks DHS policy closely but departs from it in a few places that matter for billing: no retroactive authorizations, travel time without authorization, a 9-hour daily cap on intervention, and an exclusion for simultaneous services by multiple providers.

This plan administers the **Minnesota Medical Assistance (EIDBI benefit, managed care)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Minnesota Medical Assistance (EIDBI) guide](https://carelu.com/payers/minnesota-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: No: "The annual CMDE" is on PrimeWest’s list of services that "do not require authorization prior to service delivery" (also ITP development, care conferences and travel time) [1]
- **Prior auth for treatment**: Yes: individual, group and higher-intensity intervention, family/caregiver training and observation and direction require authorization, submitted with the CMDE and ITP through the PrimeWest provider web portal; maximum span 180 days; no retroactive EIDBI authorizations except an additional CMDE [1]
- **Autism diagnosis required?**: Yes: "Have a diagnosis of ASD or a related condition," be under 21 and medically stable, then a CMDE stating medical necessity [1]

## At a glance

- **Covers ABA?:** Yes, as EIDBI for members under 21
- **Prior auth:** Intervention, family training, observation and direction; not CMDE, ITP, care conferences or travel
- **Submit via:** PrimeWest provider web portal (fax 866-431-0804 or pwserviceauth@primewest.org as backup)
- **Observation & direction:** Individual justification since Jan. 1, 2026; ~20% of direct treatment
- **Decision clock:** CMDE and ITP reviewed within 5 business days
- **Claim filing:** 180 days from date of service

## Authorization at PrimeWest

PrimeWest requires authorization before "EIDBI intervention – individual, group, and higher intensity," family and caregiver training, and intervention observation and direction, with a maximum span of 180 days. The annual CMDE, ITP development and monitoring, coordinated care conferences and travel time need none. Providers submit the CMDE summary and signature page and the ITP summary and signature page through the provider web portal; they need not arrive together, but both must be in before the authorization is completed, and the ITP may not be signed before the CMDE. PrimeWest checks the CMDE for completeness "within five business days," and within five business days of the ITP completes its integrated review, determines medical necessity and generates a notice. It "will not accept retroactive authorization requests for EIDBI services, with the exception of an additional CMDE within the calendar year." The updated DHS-7109 has been required for new ITPs since March 1, 2026 and for all ITPs since September 1, 2026. [1][3]

Since January 1, 2026 PrimeWest requires observation and direction requests to "include individual clinical justification," to be "in proportion to direct treatment," and aligned with national guidance of "20 percent of the person’s direct treatment hours"; above that, "PrimeWest Health may request unit reductions or additional documentation." [1][3]

## Billing PrimeWest for EIDBI

PrimeWest’s claim rules: the professional claim; only services already provided and approved on the authorization; never mix authorized and unauthorized services on one claim; "Do not exceed 9 hours a day for any individual or group intervention units"; include the pay-to provider, the rendering provider’s UMPI or NPI and "The supervising provider for any services that require the supervision of a QSP"; Level III claims always need the rendering provider’s UMPI; POS 12 for community, POS 11 for office and non-direct work. Its non-covered list includes "Two or more services provided by the same person at the same time" and "Simultaneous services by multiple providers at the same time," a stricter line than DHS’s. Telehealth bills "with place of service 02," modifier 93 for audio-only. "EIDBI providers are not required to bill a member’s commercial insurance before billing Medical Assistance." Claims are due "no later than 180 days from the date of service." [1][2]

## Intake gates

The questions that decide whether a family can start with PrimeWest Health, and what they have to bring.

- **Age limit**: Under 21: a child must "Be under age 21" (and be a PrimeWest member, medically stable, with ASD or a related condition). [1]
- **Diagnosis recency**: PrimeWest: a CMDE "is not required every year, but it must be performed at least once every three years or as clinically necessary." [1]
- **Who may diagnose**: PrimeWest says the child must "receive a Comprehensive Multi-Disciplinary Evaluation … by a licensed mental health professional"; the diagnosis itself follows the statute. 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. [1][4]
- **Diagnostic tools required**: PrimeWest names no instrument. 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." [1][11][12]
- **Referral required?**: No referral; the gate is a CMDE "stating a medical necessity for EIDBI services," then authorization. [1]
- **Telehealth**: "Certain EIDBI services are eligible to be provided via telehealth," with the same thresholds, rates and authorization as in person; bill "with place of service 02," modifier 93 for audio-only; no connection or site fees. PrimeWest points to DHS’s EIDBI telehealth page for which services qualify (not 0373T). [1][13]
- **Prior-auth decision time**: PrimeWest completes its CMDE completeness check "within five business days of receiving the CMDE" and, within five business days of receiving the ITP, determines medical necessity and generates the notice. No retroactive EIDBI authorizations. [1]
- **Other insurance (who pays first)**: "EIDBI providers are not required to bill a member’s commercial insurance before billing Medical Assistance. PrimeWest Health will seek reimbursement from third parties." [1]

## Delivery and billing rules

Coverage decides whether PrimeWest Health pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: PrimeWest: "EIDBI treatment services must be delivered under the clinical supervision of a QSP," providers must "meet supervision requirements in MN Stat. sec. 256B.0949, subds., 15 – 16," and services "provided in the absence of required supervision" are not paid. Statute: at least one hour of clinical supervision per 16 hours of direct treatment and monthly QSP observation and direction. [1][4]
- **Concurrent billing (97153 + 97155)**: Stricter than DHS. PrimeWest does not reimburse "Two or more services provided by the same person at the same time," "Simultaneous services by multiple providers at the same time," or "Observation and direction of two or more staff members at the same time." DHS’s policy manual allows two providers to deliver, for example, 97153 and 97155 at once; at PrimeWest, confirm before billing overlapping lines. [1][10]
- **Daily limits / MUEs**: "Do not exceed 9 hours a day for any individual or group intervention units." Otherwise PrimeWest refers to DHS’s billing grid for service limits, and caps observation and direction at about 20% of direct treatment hours without extra justification. [1][6]
- **Session-note signature**: PrimeWest does not pay for services "not documented in the member’s health service record or in the manner required by this manual or by Minnesota Rules, part 9505.2175." 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. [1][5]
- **Place of service**: POS 12 for "EIDBI services provided in a community setting, as outlined in the person’s Individual Treatment Plan," POS 11 for office-based and non-direct services (including a home office), POS 02 for telehealth. No direct intervention during homeschool or online-school instruction since January 1, 2026; family training may continue with the parent present. [1]
- **Bill as provider**: Both: the claim must include "The UMPI or NPI of the rendering provider who delivered the service" and "The supervising provider for any services that require the supervision of a QSP"; Level III services always need the rendering provider’s UMPI. [1]

## What intake should collect for PrimeWest Health

- **Member ID:** Confirm PrimeWest Health enrollment on the date of service; no retro authorizations.
- **CMDE and ITP (current DHS-7109):** Summary and signature pages for both, uploaded in the portal.
- **O&D justification:** Individual clinical rationale for 97155, around 20% of direct hours.
- **Medical stability:** PrimeWest requires the child not need 24-hour medical monitoring.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does PrimeWest Health require authorization for the CMDE?

No. The annual CMDE, ITP development, care conferences and travel time need no authorization; intervention, family training and observation and direction do.

### Can I get a retroactive EIDBI authorization from PrimeWest?

No, except an additional CMDE within the calendar year. Submit before services start.

### Can two PrimeWest providers bill at the same time?

PrimeWest’s manual excludes simultaneous services by multiple providers and observation and direction of two staff at once, which is stricter than DHS. Confirm before billing overlapping 97153 and 97155.

## Primary sources

1. [PrimeWest Health Provider Manual — Early Intensive Development and Behavioral Intervention (EIDBI) (updated 09/04/2026)](https://www.primewest.org/eidbi)
2. [PrimeWest Health Provider Manual — Billing Requirements (180-day timely filing)](https://www.primewest.org/billing-requirements)
3. [DHS — EIDBI Managed Care Organization (MCO) Contact Information Grid (October 2026)](https://www.dhs.state.mn.us/main/groups/manuals/documents/pub/DHS-312255.pdf)
4. [Minn. Stat. § 256B.0949 — Early Intensive Developmental and Behavioral Intervention (EIDBI) benefit](https://www.revisor.mn.gov/statutes/cite/256B.0949)
5. [Laws 2026, ch. 95, art. 4, secs. 23–26 — EIDBI definitions, QSP observation and direction, new documentation subdivision 19](https://www.revisor.mn.gov/laws/2026/0/Session+Law/Chapter/95/)
6. [DHS — EIDBI billing grid (August 2026)](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&noSaveAs=1&dDocName=DHS16_195657)
7. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
8. [42 CFR 433.139 — Medicaid third-party liability, incl. pay-and-recover for EPSDT (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
9. [PrimeWest Health — Provider Updates](https://www.primewest.org/provider-updates)
10. [EIDBI Benefit Policy Manual — EIDBI services (updated 1/6/26)](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_195211)
11. [EIDBI Benefit Policy Manual — Eligibility for EIDBI services](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_195213)
12. [EIDBI Benefit Policy Manual — Comprehensive multi-disciplinary evaluation (CMDE) (updated 11/7/25)](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_195210)
13. [EIDBI Benefit Policy Manual — Telehealth services (updated 9/10/26)](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS-292812)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.