---
title: "South Country Health Alliance ABA / EIDBI coverage: the intake guide."
url: "https://carelu.com/payers/south-country-health-alliance-minnesota"
markdown_url: "https://carelu.com/payers/south-country-health-alliance-minnesota.md"
state: MN (Minnesota)
payer: South Country Health Alliance
kind: Medicaid managed care plan (MCO)
parent_program: Minnesota Medical Assistance (EIDBI benefit, managed care)
description: "How South Country Health Alliance covers ABA under the EIDBI benefit: its prior-authorization list and form #4894, 180-day authorizations, 5-business-day decisions, 180-day claim filing, telehealth billing, and appeal deadlines."
last_reviewed: October 2026
---

# South Country Health Alliance ABA / EIDBI coverage: the intake guide.

_Payer Guide · South Country Health Alliance · Minnesota · Last updated October 2026 · 13 primary sources_

> Medical Assistance plan: EIDBI on its BH prior-auth list with form #4894, the CMDE and ITP; 5-business-day decisions; 180-day filing.

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.

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** _(plan-dependent)_: 97151 UB appears on South Country’s EIDBI prior-authorization row with the DHS threshold "80 units per calendar year (1 CMDE allowed annually)"; the row reads "Thresholds vary, see DHS Billing Grid," so authorization applies above the grid’s free annual CMDE [1][9]
  - Ask the plan: South Country Provider Services, 888-633-4055: confirm the first annual CMDE needs no authorization.
- **Prior auth for treatment**: Yes: "Authorization Required - authorization cannot exceed 180 day time span" for 97153, 97154, 97155, 97156, 97157 (UB), H0046 and 0373T, on the EIDBI Authorization form (#4894) with the CMDE and ITP [1]
- **Autism diagnosis required?**: Yes: South Country’s list labels EIDBI "[ages 21 & under]" and points to the MHCP manual; the statutory rule applies (ASD or a related condition diagnosed by a physician, APRN, PA or mental health professional) [1][7]

## At a glance

- **Covers ABA?:** Yes, as EIDBI (list says "ages 21 & under"; statute: under 21)
- **Prior auth:** 97153–97157, H0046, 0373T; 97151 above the DHS threshold
- **Form:** EIDBI Authorization (#4894) plus the CMDE and ITP
- **Decision clock:** 5 business days standard; 48 hours expedited
- **Claim filing:** 180 days from date of service
- **Appeals:** 60 days from the notice

## Authorization at South Country

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]

## Claims, telehealth and appeals

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]

## Intake gates

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

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: No. DHS’s October 2026 grid, for South Country: "No referral required for in or out of network providers." [6]
- **Telehealth**: 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]
- **Prior-auth decision time**: "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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether South Country Health Alliance 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**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Place of service** _(ask the plan)_: 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).
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for South Country Health Alliance

- **Member ID:** Confirm South Country PMAP or MinnesotaCare enrollment.
- **Form #4894 + CMDE + ITP:** All three go with the authorization request.
- **Other insurance:** Record it; EIDBI requests do not need a primary-payer attempt first.

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

## Common questions

### What form does South Country use for EIDBI?

The EIDBI Authorization form (#4894), with the CMDE and ITP. Authorizations cannot exceed 180 days.

### How long do I have to file a South Country claim?

180 days from the date of service (since January 1, 2024).

## Primary sources

1. [South Country Health Alliance — Behavioral Health Prior Authorization and Notification List (form 7212, updated 3/5/2025)](https://mnscha.org/wp-content/uploads/7212.pdf)
2. [South Country Provider Manual Ch. 6 — Service Authorizations & Notification Standards (Feb. 2026)](https://mnscha.org/wp-content/uploads/Ch6_02272026.pdf)
3. [South Country Provider Manual Ch. 4 — Provider Billing (July 2026)](https://mnscha.org/wp-content/uploads/Ch4_07292026.pdf)
4. [South Country Provider Manual Ch. 33 — Telehealth (Feb. 2026)](https://mnscha.org/wp-content/uploads/Ch33_02272026.pdf)
5. [South Country Provider Manual Ch. 14 — Member Grievances and Appeals, Minnesota Health Care Programs (May 2026)](https://mnscha.org/wp-content/uploads/Ch14_05042026.pdf)
6. [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)
7. [Minn. Stat. § 256B.0949 — Early Intensive Developmental and Behavioral Intervention (EIDBI) benefit](https://www.revisor.mn.gov/statutes/cite/256B.0949)
8. [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/)
9. [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)
10. [MHCP Provider Manual — Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit (revised Sept. 14, 2026)](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_195658)
11. [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)
12. [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)
13. [South Country Health Alliance — Provider Updates & Bulletins](https://mnscha.org/providers/provider-news-updates/)
14. [EIDBI Benefit Policy Manual — Clinical supervision (updated 9/15/26)](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_195399)
15. [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)
16. [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)
17. [EIDBI Benefit Policy Manual — Medical necessity criteria](https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_195405)
18. [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)
19. [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.