South Country Health Alliance is one of the eight Medical Assistance plans on DHS’s October 2026 EIDBI grid. EIDBI sits on its Behavioral Health Prior Authorization and Notification List for PMAP and MinnesotaCare, and its provider manual sets the general authorization clock, filing limits and telehealth billing rules.
South Country’s list (updated 3/5/2025) puts "Behavioral Health EIDBI [ages 21 & under]" on PMAP and MinnesotaCare, lists 97151, 97153, 97154, 97155, 97156 and 97157 (UB), H0046 and 0373T, notes for 97151 "80 units per calendar year (1 CMDE allowed annually), limit of 8 hours per day," says "Thresholds vary, see DHS Billing Grid," and requires authorization that "cannot exceed 180 day time span" on the "Early Intensive Developmental and Behavior Interventions (EIDBI) Authorization (Form #4894), the CMDE and ITP." Its authorization chapter sets a standard decision "within 5 business days from the date the request was received" and an expedited Medicaid decision within "48 hours including a business day." Unlike most services, EIDBI requests do not need proof of a good-faith attempt with Medicare or other insurance first: "Except for home care and EIDBI authorization requests, South Country will not consider a request … for a member with Medicare or TPL unless the provider has made a good faith effort" with the primary payer.[1][2]
Since January 1, 2024, claims "must be received by South Country no later than 180 days from the date of service"; corrected claims within 180 days of the remittance advice; Medicare and TPL claims within six months of the primary’s payment or denial, or 180 days from service if later. Claims use the NPI or UMPI. Telehealth claims "require Place of Service 02 or 10," with modifier 93 for audio-only. Members must file appeals "within 60 days of the date of the" notice of action.[3][4][5]
The questions that decide whether a family can start with South Country Health Alliance, and what they have to bring. Each maps onto something intake should ask on the first call.
South Country labels EIDBI "[ages 21 & under]"; the statute and DHS limit it to people "under 21 years of age," so expect coverage to end at the 21st birthday.[1][7]
South Country 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.[7][18]
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."[18][16]
No. DHS’s October 2026 grid, for South Country: "No referral required for in or out of network providers."[6]
South Country telehealth claims "require Place of Service 02 or 10," modifier 93 for audio-only. Which EIDBI services qualify follows the statute and DHS. 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][7][19]
"Standard review timeframe for an authorization decision is within 5 business days from the date the request was received"; expedited Medicaid requests "48 hours including a business day."[2]
EIDBI authorization requests are exempt from South Country’s rule requiring a good-faith attempt with Medicare or other insurance first; DHS’s pay-and-chase policy means the commercial plan need not be billed first. South Country’s billing chapter still asks for primary-payer information on claims when it exists.[2][3][10]
Coverage decides whether South Country Health Alliance 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.
South Country publishes no EIDBI supervision rule of its own; it points to the MHCP manual. 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)).[1][7][8][14]
South Country’s list: "Thresholds vary, see DHS Billing Grid," and for 97151 "80 units per calendar year (1 CMDE allowed annually), limit of 8 hours per day." Grid daily limits: 97153 and 0373T 8 hours, 97154 4.5 hours, 97155 6 hours, 97156/97157 4 hours.[1][9]
South Country 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.[8][15]
Not addressed for EIDBI in the South Country documents read.[1]
Ask the plan: South Country Provider Services, 888-633-4055: ask whether 97153 and 97155 by different staff may be billed for the same time.
Not addressed for EIDBI beyond telehealth (POS 02 or 10).[4]
Ask the plan: South Country Provider Services, 888-633-4055: confirm in-person EIDBI POS codes (DHS uses 11 and 12).
South Country requires the NPI or UMPI on claims but publishes no EIDBI rendering/supervising rule.[3]
Ask the plan: South Country Provider Services, 888-633-4055: ask whether the supervising QSP must be on the claim, as DHS requires.
The EIDBI Authorization form (#4894), with the CMDE and ITP. Authorizations cannot exceed 180 days.
180 days from the date of service (since January 1, 2024).
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo