What must an EIDBI individual treatment plan include?

Under Minn. Stat. § 256B.0949, subd. 6, the ITP must state the medically necessary treatment and services, the treatment modality with baseline measures and projected accomplishment dates, the frequency, intensity, location, and duration of each service, the level of caregiver training and counseling, environmental modifications, significant changes in the person's condition or family circumstances, techniques matched to the person's communication and learning style, the QSP's name, progress monitoring results and goal mastery data, discharge criteria, and a transition plan. It is developed by the QSP, a Level I, or a Level II provider.

How often is EIDBI progress monitoring required?

Minn. Stat. § 256B.0949, subd. 7 requires ITP progress monitoring after each six months of treatment, or more frequently if the CMDE provider or QSP determines it is needed. Progress monitoring must decide whether the person is progressing toward targeted functional and generalizable goals, adjust the ITP as needed, include input from the legal representative or primary caregiver, include observation of the person by the QSP, Level I, or Level II provider, and document the person's current level of performance on the primary goal domains.

What should an EIDBI session note contain?

The EIDBI Benefit Policy Manual requires a health service record for every person and documentation of every EIDBI service delivered. To support a claim, a session note should show the date, the start and stop times of active delivery, the procedure code and setting, the rendering provider and level, the ITP goals targeted, the interventions used, the person's response, the data collected, and the provider's signature and credentials. Since December 2025, breaks and other pauses in delivery must be excluded from billed time.

How is EIDBI observation and direction documented?

Observation and direction (CPT 97155) must be authorized, individualized, and tied to the person's documented clinical need. The ITP should state the amount requested, generally about 20% of total intervention time on 97153, 97154, and 0373T, and the clinical justification for it, which is required for services requested on or after January 1, 2026. Each session note should record who provided the observation and direction, which treatment provider was observed, what protocol changes were directed, and whether it was in person or by telehealth.

Does EIDBI require a CMDE every year?

The statute describes the CMDE as the evaluation that establishes eligibility and medical necessity and does not set a fixed annual interval in the text of § 256B.0949, subd. 5. Payers do require updated clinical documentation with authorization requests, and Blue Cross, for example, asks for the completed ITP with initial, six-month, and annual requests. Check the current EIDBI Benefit Policy Manual and your medical review agent's requirements for when a CMDE must be updated, and document the reason for any re-evaluation.

What do DHS auditors look for in EIDBI records?

Reviewers compare each claim line to the record behind it: an eligible person, a current CMDE, an ITP that authorizes that service at that frequency, a session note whose active-delivery minutes support the units, a rendering provider qualified at the right level with a completed background study for that location, a supervising QSP who was an agency employee, and supervision and observation and direction logs that meet the statutory minimums. Under § 256B.0949, subd. 18, DHS may conduct unannounced inspections and withhold payment or terminate enrollment for noncompliance.

EIDBI documentation: ITP, session notes, and progress monitoring

Short answer

EIDBI documentation in Minnesota starts with a comprehensive multi-disciplinary evaluation (CMDE) and an individual treatment plan (ITP) that contains the elements in Minn. Stat. § 256B.0949, subd. 6, including baseline measures, frequency and duration of each service, the QSP's name, and discharge criteria. Every service delivered must be recorded in the person's health service record, ITP progress monitoring is required after each six months of treatment, and supervision, observation and direction, and family training must be documented against the agency's statutory minimums.

Key takeaways

The CMDE must record direct observation of developmental skills, functional behavior, needs, and capacities, plus medical information from a physician, APRN, or PA.
The ITP must list each service's frequency, intensity, location, and duration, baseline measures with target dates, the QSP's name, progress and goal mastery data, discharge criteria, and a transition plan.
ITP progress monitoring is required after each six months of treatment, or sooner if the CMDE provider or QSP decides, and must include caregiver input and direct observation.
A session note must support every unit billed: clock times of active delivery, the code, the ITP goals targeted, what the provider did, the person's response, and the data collected.
Supervision records must show at least one hour of clinical supervision per 16 hours of direct treatment per person and observation and direction at least monthly.
EIDBI is a high-risk service under pre-payment review and Minnesota Revalidate 2026, so records may be requested before a claim is paid.

EIDBI documentation is the evidence that an Early Intensive Developmental and Behavioral Intervention (EIDBI) claim was medically necessary, authorized, delivered by a qualified person, and supervised. Minn. Stat. § 256B.0949 sets the content of the comprehensive multi-disciplinary evaluation (CMDE) in subd. 5, the individual treatment plan (ITP) in subd. 6, and progress monitoring in subd. 7. The Department of Human Services (DHS) EIDBI Benefit Policy Manual adds the rule that the agency must keep a health service record for every person and document every service delivered.

As of September 2026 those records are read by more people than they used to be. EIDBI is one of 14 high-risk services under DHS pre-payment review, EIDBI agencies were revalidated in the first half of 2026, and state and federal prosecutors have brought Medicaid fraud cases involving EIDBI providers. None of that changes what the statute requires; it changes how quickly an agency needs to produce it.

This guide covers the record in the order a reviewer reads it: the CMDE, the ITP, the session note and its data, progress monitoring, supervision and observation and direction, family training, coordination with schools, and what an audit request looks like. Codes and units are in the EIDBI billing codes guide.

What the CMDE must contain

The CMDE establishes eligibility and medical necessity, and it is the foundation the ITP is built on. Under subd. 5 it must include:

An assessment of the person's developmental skills, functional behavior, needs, and capacities based on direct observation.
Medical information from a physician, advanced practice registered nurse, or physician assistant.
Input from the family, school personnel, and child care providers where available.
The legal representative's or primary caregiver's preferences for involvement in treatment.
Information about the treatment modalities available to the person.

The CMDE provider reviews the diagnostic assessment and confirms that the person meets the ASD or related condition criteria. Subd. 5a requires the CMDE provider to be a physician, APRN, physician assistant, mental health professional, or qualifying clinical trainee with at least 2,000 hours of clinical experience with ASD or a related condition, or equivalent graduate coursework. The CMDE provider does not have to belong to the EIDBI agency, so the agency's file should hold a copy of the completed CMDE, the date, and the provider's credentials. The EIDBI CMDE guide covers billing, update timing, and the deficiencies that cause pended requests. The EIDBI provider requirements guide covers the qualification rules in detail.

Individual treatment plan requirements

The ITP is developed by the qualified supervising professional (QSP), a Level I provider, or a Level II provider, based on the CMDE. Subd. 6 lists what it must contain, and the list doubles as the authorization checklist because the medical review agent reads the ITP to decide what to approve.

ITP element	What a reviewer checks
Medically necessary treatment and services	Each service requested traces to a CMDE finding
Treatment modality, baseline measures, and projected accomplishment dates	Baselines are numeric and dated; targets have dates
Frequency, intensity, location, and duration of each service	Matches the units on the authorization request and the claims that follow
Level of legal representative or caregiver training and counseling	Supports 97156 and 97157 requests
Environmental modifications	Named, not generic
Significant changes in condition or family circumstance	Updated when they happen
Techniques matched to communication and learning style	Consistent with the modality named
Name of the QSP	An agency employee on the dates covered
Progress monitoring results and goal mastery data	Present after the first six months
Discharge criteria and transition plan	Specific to the person

Since January 1, 2026 the ITP must also carry the clinical justification for observation and direction (97155). DHS expects 97155 to be about 20% of total intervention time on 97153, 97154, and 0373T unless the ITP explains, for this person, why more is needed. DHS's "How to complete ITP and Progress Monitoring" instructions for form DHS-7109 describe where that justification goes.

Compliance note: an ITP that requests observation and direction equal to or greater than direct treatment hours, or that uses the same supervision ratio for every person on the caseload, is the pattern DHS named as unacceptable in December 2025. Write the justification per person, and cite the data that supports it.

Session note elements and data collection

The EIDBI Benefit Policy Manual requires a health service record for every person served and documentation in that record of every EIDBI service delivered to the person and family. A session is a period in which a qualified provider delivers an EIDBI service; the agency may define sessions further, but every intervention session must meet the manual's requirements.

The statute does not enumerate session note fields the way Chapter 245I does for mental health services, so build the note around what the claim line must prove:

Person, date, and setting, including the telehealth place of service when applicable.
Start and stop times of active delivery. DHS provider news from December 5, 2025 says billing must pause during provider breaks, meals, phone calls, administrative tasks, or any time the provider steps away. Record each segment.
Procedure code and provider level of the rendering provider, plus the supervising QSP where required.
ITP goals and objectives targeted in this session.
Interventions and protocols used, in the modality named in the ITP.
Person's response and the data collected: trial data, frequency counts, duration, or whatever the ITP's baseline measures call for.
Caregiver presence and participation when 97156 or 97157 is billed, or when direct intervention happens during homeschool or online school hours (where only caregiver training is allowed since January 1, 2026).
Signature, credentials, and date of the rendering provider.

Data collection is not separate from the note. Subd. 6 requires the ITP to carry progress monitoring results and goal mastery data, and subd. 7 requires progress monitoring to document the person's current level of performance on the primary goal domains. That performance level comes from session data, so the data has to be captured in a form that can be summarized every six months.

Progress monitoring every six months

Subd. 7 requires ITP progress monitoring after each six months of treatment, or more often if the CMDE provider or QSP determines it is needed. The progress monitoring must:

Determine whether progress is being made toward targeted functional and generalizable goals.
Adjust the ITP as needed.
Include input from the person's legal representative or primary caregiver.
Include observation of the person by the QSP, Level I, or Level II provider.
Document the person's current level of performance on the primary treatment goal domains.

The progress monitoring report is what the medical review agent reads at the six-month authorization point. Effective January 1, 2026, Acentra Health reviews CMDEs and ITPs within seven calendar days for fee-for-service authorizations and gives providers 10 calendar days to answer a pended request, so the report and the data behind it should be ready before the authorization period ends.

Supervision, observation and direction, and family training records

Subd. 16 sets the agency's supervision minimums, and reviewers ask for the logs that prove them. The EIDBI QSP requirements guide explains the QSP's role behind each of these entries.

Clinical supervision: at least one hour for every 16 hours of direct treatment per person, unless the ITP authorizes otherwise. Log the date, duration, supervisor, supervisee, and person.
Observation and direction: at least once per month, delivered by the QSP or other qualified staff. No more than two consecutive monthly sessions may be by telehealth, so the log needs a delivery mode column.
Level-specific supervision: Level I providers without 2,000 supervised hours receive observation and direction from the QSP at least monthly; some Level II pathways require it at least twice per month or weekly until 1,000 hours. Track hours toward those thresholds.
Family and caregiver training (97156, 97157): document who attended, the skills taught, the caregiver's practice and response, and how the session connects to the ITP's stated level of caregiver training. Group family training notes must identify the participants without disclosing other families' protected health information in each family's record.

Coordinated care conferences, a covered service under subd. 13, are voluntary meetings with the person and family to review the CMDE or progress monitoring and coordinate across providers. Document who attended, what was reviewed, and any ITP changes that resulted.

Coordination with schools and other providers

The CMDE may draw on school personnel, and the ITP's transition plan usually involves them. Since January 1, 2026, EIDBI providers may not deliver or bill 97153, 97154, or 0373T during homeschool or online school instruction; only clinically necessary caregiver training under 97156 with the parent present is covered in that time. Keep the person's school schedule in the record so session times can be checked against it, and document communication with the school, the county case manager, and any other treating provider with dates and outcomes.

What an audit request looks like now

Under subd. 18 the commissioner may conduct unannounced site visits and may withhold payment or suspend or terminate an agency's enrollment for failing to comply with applicable law. Three things have raised the frequency of record requests as of September 2026:

Pre-payment review. Since the process announced October 29, 2025, DHS's vendor can hold EIDBI claims and ask for the documentation before paying.
Minnesota Revalidate 2026. EIDBI agencies were designated high risk, revalidated by May 31, 2026, and remain subject to unannounced site visits.
Fraud enforcement. The Minnesota Attorney General and federal prosecutors have charged providers in EIDBI and other home and community-based programs. Those cases are about billing for services that were not delivered as documented, which is why the session note and the supervision log now carry more weight than the ITP alone.

When a request arrives, the reviewer wants the chain for each sampled claim line: eligibility, CMDE, ITP, authorization, session note with data, provider qualification and background study for that location, and the supervision record for that period. The DHS audit preparation checklist explains how to run that sample yourself. Access to the record also has to be controlled and logged; the HIPAA guide for Minnesota agencies covers audit logs and role-based access.

How Trustora helps

Trustora's EIDBI module stores the CMDE, ITP, and progress monitoring as structured records with the subd. 6 elements as required fields, so an ITP cannot be finalized without baselines, per-service frequency and duration, the QSP's name, discharge criteria, and the 97155 justification. Session notes capture segmented clock times, the ITP goals targeted, and trial or frequency data, and the six-month progress monitoring report pulls its current-performance figures from that data.

Supervision and observation and direction sessions are logged against the one-hour-per-16-hours and monthly minimums, with the delivery mode recorded to enforce the two-consecutive-telehealth limit. The one-click DHS audit binder assembles the full chain for any person and date range, and the append-only audit log shows who viewed or changed each record. See the platform overview for the EIDBI workflow.

Frequently asked questions

What must an EIDBI individual treatment plan include?: Under Minn. Stat. § 256B.0949, subd. 6, the ITP must state the medically necessary treatment and services, the treatment modality with baseline measures and projected accomplishment dates, the frequency, intensity, location, and duration of each service, the level of caregiver training and counseling, environmental modifications, significant changes in the person's condition or family circumstances, techniques matched to the person's communication and learning style, the QSP's name, progress monitoring results and goal mastery data, discharge criteria, and a transition plan. It is developed by the QSP, a Level I, or a Level II provider.
How often is EIDBI progress monitoring required?: Minn. Stat. § 256B.0949, subd. 7 requires ITP progress monitoring after each six months of treatment, or more frequently if the CMDE provider or QSP determines it is needed. Progress monitoring must decide whether the person is progressing toward targeted functional and generalizable goals, adjust the ITP as needed, include input from the legal representative or primary caregiver, include observation of the person by the QSP, Level I, or Level II provider, and document the person's current level of performance on the primary goal domains.
What should an EIDBI session note contain?: The EIDBI Benefit Policy Manual requires a health service record for every person and documentation of every EIDBI service delivered. To support a claim, a session note should show the date, the start and stop times of active delivery, the procedure code and setting, the rendering provider and level, the ITP goals targeted, the interventions used, the person's response, the data collected, and the provider's signature and credentials. Since December 2025, breaks and other pauses in delivery must be excluded from billed time.
How is EIDBI observation and direction documented?: Observation and direction (CPT 97155) must be authorized, individualized, and tied to the person's documented clinical need. The ITP should state the amount requested, generally about 20% of total intervention time on 97153, 97154, and 0373T, and the clinical justification for it, which is required for services requested on or after January 1, 2026. Each session note should record who provided the observation and direction, which treatment provider was observed, what protocol changes were directed, and whether it was in person or by telehealth.
Does EIDBI require a CMDE every year?: The statute describes the CMDE as the evaluation that establishes eligibility and medical necessity and does not set a fixed annual interval in the text of § 256B.0949, subd. 5. Payers do require updated clinical documentation with authorization requests, and Blue Cross, for example, asks for the completed ITP with initial, six-month, and annual requests. Check the current EIDBI Benefit Policy Manual and your medical review agent's requirements for when a CMDE must be updated, and document the reason for any re-evaluation.
What do DHS auditors look for in EIDBI records?: Reviewers compare each claim line to the record behind it: an eligible person, a current CMDE, an ITP that authorizes that service at that frequency, a session note whose active-delivery minutes support the units, a rendering provider qualified at the right level with a completed background study for that location, a supervising QSP who was an agency employee, and supervision and observation and direction logs that meet the statutory minimums. Under § 256B.0949, subd. 18, DHS may conduct unannounced inspections and withhold payment or terminate enrollment for noncompliance.

Sources and further reading

Cite this article

Trustora Editorial Team. (2026, September 6). EIDBI documentation: ITP, session notes, and progress monitoring. Trustora. https://trustora.com/blog/eidbi-documentation-itp-and-session-notes

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This article is general information for Minnesota agencies, not legal, clinical, or billing advice. Minnesota DHS policy changes often. Confirm current requirements in the MHCP Provider Manual, the Minnesota Statutes, and DHS provider notices before acting on anything here.