Page updated: 2/9/26

Legal authority

CMS-approved state plan amendment – 2017 (PDF), CMS-approved state plan amendment – 2018 update (PDF), CMS-approved state plan amendment – 2019 update (PDF), Minn. Stat. §256B.0949

Definitions

Individual treatment plan (ITP) development and progress monitoring: An EIDBI service that covers the development of the person’s initial ITP and ongoing monitoring of the person’s progress.

ITP and Progress Monitoring, DHS-7109: The person-centered, individualized plan of care for a person who meets medical necessity criteria for the EIDBI benefit. The ITP incorporates the person’s and family’s information from the comprehensive multi-disciplinary evaluation (CMDE). The qualified supervising professional (QSP) uses DHS-7109 to document the person’s initial plan of care and progress-monitoring updates.

Medical necessity determination: A decision made by a qualified professional about whether a person with autism spectrum disorder (ASD) or a related condition has a medical need for and, therefore, is eligible to receive EIDBI services.

Person-centered services: Services that:

Overview

This page provides guidance to QSPs and otherwise qualified EIDBI providers on how to complete ITP and Progress Monitoring, DHS-7109.

The QSP must:

For training on how to complete the ITP, refer to EIDBI – Individual provider trainings – CMDE and ITP Overview.

Type of ITP

In this section, the QSP must indicate which type of ITP:

Section A. Personal information for person who receives services

In section A, the QSP must document the person’s information (e.g., name, gender, date of birth, address, caregiver/guardian[s], insurance, living situation, insurance, race/ethnicity, language).

Section B. Provider information

In section B, the QSP must document the EIDBI provider agency and QSP information.

If the agency has multiple EIDBI locations, the QSP must indicate the specific taxonomy code for the location where the person will receive services.

Section C. EIDBI service authorization request

In section C, the QSP must provide an overview of their treatment recommendations for the person, including:

The average number of hours per week cannot exceed the limits listed on EIDBI billing grid (PDF).

Progress monitoring frequency

In the EIDBI progress monitoring frequency section, the QSP must document how often the provider team will monitor the person’s progress.

Clinical supervision frequency

In the EIDBI clinical supervision frequency section, the QSP must document that the QSP clinical supervision frequency meets the requirement of one hour for every 16 hours of direct treatment, unless otherwise specified.

Exceptions

If the standard 1:16 clinical supervision ratio is not appropriate based on the person’s individual needs, the QSP may request an exception. The QSP must clearly describe the alternate supervision plan in this section and support it by medical necessity. Justification must include:

The medical review agency must review and approve all exceptions to the standard supervision ratio during the service authorization process. For more information, refer to EIDBI – Clinical supervision.

Observation and direction frequency

In the EIDBI observation and direction frequency section, the QSP must document:

For more information, refer to EIDBI – Observation and direction.

Exceptions

If a person’s clinical needs require observation and direction above the general guideline (i.e., 20% of total direct intervention), the QSP may request an exception. When the QSP requests the exception, they must clearly explain the following information in the ITP:

1. Why the general guideline (i.e., 20% of total direct intervention) is inadequate.

2. How additional observation and direction is medically necessary for the person and supports treatment outcomes.
Note: General statements, provider staffing models, agency practices or broad descriptions of best practices do not establish medical necessity.

3. Clinical factors that make additional observation and direction necessary for the person, such as:

4. How the requested intensity aligns with the overall supervision documented in the plan. The QSP must use objective, person-specific information rather than agency practices.

5. The plan to return to the general guideline (i.e., 20% of total direct intervention).

For more information, refer to EIDBI – Observation and direction.

Section D. EIDBI service authorization request details

The QSP must base their service authorization requests on the person’s medical necessity determination and CMDE recommendations. A service included in the ITP must meet all applicable requirements listed on EIDBI – Medical necessity criteria.

In section D, the QSP must provide specific information about each service they request for authorization, including:

The QSP must review the service units and adjust the requested units accordingly. Reference the EIDBI billing grid (PDF) for service limits.

The recommended treatment intensity in section C should match the number of units requested for each service in section D.

Section E. Person- and family-centered planning

In section E, the QSP must describe:

The information the QSP collects in this section should inform the person’s overall goal development in section G.

Section F. FBA

DHS recommends the QSP complete and document a functional behavior assessment (FBA) if they either:

In section F, the QSP must:

If the QSP does not complete an FBA but does note interfering behaviors in the ITP, they must include the reason they did not complete an FBA and how they will evaluate and address those behaviors throughout services.

Section G. Primary EIDBI treatment goals

In section G, the QSP must define and describe both:

The person’s goals and objectives must:

A well-written objective contains the following elements:

Long-term treatment goal

In the long-term treatment goal subsection, the QSP must:

Long-term benchmark goals include objectives the person should master before they transition out of EIDBI services. These goals should become more defined and measurable as the person approaches discharge from EIDBI services.

Developmental goal domains

In the development goal domains subsection, the QSP must identify specific objectives according to developmental domain. The QSP does not need to include an objective for each domain.

For each applicable objective, the QSP must document:

Status

In the status subsection, the QSP must add or update goals by selecting one of the following options that best describes the person’s progress for that goal:

The QSP must indicate the reason or data for the status they selected. For more information, refer to the progress monitoring section on this page.

Section H. Summary of current services

In section H, the QSP must document all other services the person receives, such as:

For each service the person receives, the QSP must indicate the frequency, intensity and duration, provider information and discharge date, if applicable.

Section I. Coordinated care conference

The coordinated care conference is a covered service under the EIDBI benefit. For more information, refer to EIDBI – Coordinated care conference.

In section I, the QSP must document:

If a coordinated care conference did not occur, the QSP must indicate the reason they did not conduct one. For more information on coordinating with other services, refer to the coordination with other services section on EIDBI – Services.

Section J. Progress monitoring

In the person’s initial ITP, the QSP must enter “N/A” in the progress monitoring section.

The QSP must submit an ITP progress monitoring update after each six months of treatment or more frequently as determined by the CMDE provider or QSP. This update determines if the person is making progress toward goals outlined in the ITP. In the progress monitoring section, the QSP must document the person’s progress toward ITP goals and objectives during each update.

Adjusting the ITP based on progress monitoring

Based on the ITP progress monitoring results, the QSP must adjust the ITP as needed and document one of the following situations:

As a person makes progress toward their goals/objectives, the EIDBI provider team, in consultation with the person’s caregiver/guardian, must update the person’s ITP. These updates must include:

Frequency of progress monitoring

Progress monitoring should occur based on medical necessity. The QSP should:

Treatment plan progress monitoring

Providers may use treatment plan progress monitoring to compile and analyze data:

During progress monitoring, the QSP or other qualified professional should focus on analysis of overall skill acquisition related to the primary treatment goals and any interfering behaviors being addressed. This differs from data collection during treatment sessions.

Involving the person’s entire treatment team in the decision-making, goal setting and review process will help make sure EIDBI services are effective, individualized and aligned with the person’s treatment plan.

Mastering goals before the six-month interval

If a person masters their goals or needs adjustments based on data, the QSP and other qualified professionals should update the ITP and review it with the person’s caregiver/guardian. They do not need to submit updates to the medical review agent unless they change the approved service frequency, intensity or duration. They should submit progress updates at the next six-month or regular authorization interval.

Section K. Transition planning

In section K, the QSP must describe the plan to help the person and family transition to other services (refer to EIDBI transition and/or discharge summary, DHS-7109A and the related section below). The plan must include:

All ITPs must include a general transition plan, even if no transition is currently planned. As the person’s discharge from EIDBI services approaches, the QSP must update the transition plan to be more specific to the person’s and family’s needs.

Section L. Safety planning

DHS encourages EIDBI providers, in coordination with the person’s caregiver/guardian, to create safety plans to identify safety risks and prevent emergencies.

In section L, the QSP must document:

Note: If the person does not have a safety plan in place, the QSP must document:

For details about safety plans and a template, refer to the Addendum F: Safety Plan section on this page.

For additional safety plan templates and resources, refer to the Minnesota Autism Resource Portal – Safety.

ITP signature page

Once DHS-7109 is complete, the following people must sign and date the ITP signature page:

The interpreter signature date does not affect service authorization dates.

The signatures and dates must be either handwritten or use an approved electronic signature with a time and date stamp (refer to MHCP Eligibility Policy Manual – Signature).

The signatures confirm understanding and agreement with the treatment plan and service recommendations. They serve as consent for the person to begin or continue receiving EIDBI services.

Note: Only people who can consent to treatment and make legal decisions can sign the form. This may not include all caregivers/guardians. Providers must make sure the person who signs the form has the legal authority to do so.

Timeline

The ITP is considered complete on the date the last person signs the signature page. Signatures do not need to occur on the same day, but service authorization requires the caregiver/guardian’s signature.

The CMDE may be completed and signed on the same day as the ITP, but the CMDE cannot be completed after the ITP.

Signature pages

ITP Signature Page – English (PDF)
ITP Signature Page – Hmong (PDF)
ITP Signature Page – Russian (PDF)
ITP Signature Page – Somali (PDF)
ITP Signature Page – Spanish (PDF)
ITP Signature Page – Vietnamese (PDF)
Note: The English version also is included in ITP and Progress Monitoring, DHS-7109.

EIDBI transition and/or discharge summary (DHS-7109A)

Providers must follow EIDBI policy, as described throughout the EIDBI Policy Manual, and consult with the person’s caregiver/guardian about the person’s transition or discharge plan.

When a transition or discharge occurs, the QSP should download and complete EIDBI transition and/or discharge summary, DHS-7109A electronically. On DHS-7109A, the QSP must:

The signature of the caregiver/guardian on DHS-7109A indicates they approve of the transition/discharge plan. If the caregiver/guardian does not agree with the transition/discharge plan, review EIDBI – Rights and responsibilities (including appeal rights).

For step-by-step instructions on transferring agencies, refer to EIDBI – Services.

For information about service termination, refer to EIDBI – Medical necessity criteria.

For help with technical issues downloading the form, refer to DHS – Frequently asked questions about eDocs.

Addendum C: Week-In-The-Life Schedule (optional)

ITP and Progress Monitoring Week-In-The-Life Schedule (Addendum C), DHS-7109C (PDF) is an optional document to help providers and families identify potential service times and schedule conflicts.

When the provider completes Addendum C, they should account for all hours in the week (i.e., complete all available boxes).

Addendum C should reflect the recommendations in the ITP, including:

If the person does not have activities or therapy sessions scheduled, the QSP should use a phrase such as “no activity scheduled” or “free time.”

The QSP is not required to submit this document for authorization.

Addendum F: Safety Plan (optional)

EIDBI Safety Plan Template, DHS-7109F is an optional document to help providers create a safety plan.

A safety or crisis plan is a plan of action created before a crisis occurs, so the person and their support network know exactly what to do in an emergency. The QSP and other qualified EIDBI providers should develop the plan with all team members, including natural supports and other providers.

A person’s safety needs can change as they get older or when they experience a sudden change in their routine. The QSP must update the safety plan on a regular basis.

A case manager or support planner also can help the person and their family develop a plan or coordinate additional supports to prevent or recover from an emergency or crisis.