Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Enrollment Criteria and Forms
Revised: February 23, 2024
Review the EIDBI section of the Minnesota Health Care Programs (MHCP) Provider Manual, EIDBI Benefit Policy Manual or take the EIDBI 101 training for providers for more information about the EIDBI benefit.
Background Studies (BGS) using NETStudy 2.0
All individuals who have direct contact (in-person or via telehealth) with people who receive EIDBI services and their legal representatives, including volunteers, subcontractors and temporary staff, at MHCP-enrolled EIDBI agencies must have a completed, passed criminal background check through NETStudy 2.0 using the agency ID assigned to the facility. Rendering providers who do not have this documentation on file could be subject to monetary recovery of claims billed. Refer to the Background studies webpage to learn how to contact the Background Study Division for questions regarding NETStudy 2.0.
All EIDBI provider agencies must complete the Request for EIDBI NETStudy 2.0 Agency ID Number (DHS-3891A) (PDF) to have BGS create your NETStudy 2.0 account and assign an agency ID.
How to enroll as an EIDBI Provider Agency
Use the Minnesota Provider Screening and Enrollment (MPSE) portal by following the instructions on the Registration and access webpage or complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462.
Requirements and additional information
Enrollment requirements for EIDBI provider agencies | Additional information |
Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) | |
Must have a qualified supervising professional (QSP) affiliated to the EIDBI agency | |
Application fee | |
MHCP will also conduct a site visit as part of the enrollment process. Please allow SIRS up to an additional 60 days for screening time. Refer to the Provider Screening Requirements webpage for more information.
Enrolling Individual EIDBI Providers
Comprehensive Multi-Disciplinary Evaluation (CMDE) services or qualified supervising professional (QSP) providers
You must be enrolled as one of the following provider types to provide CMDE services or to identify yourself as the QSP:
CMDE providers must submit the EIDBI Comprehensive Multi-Disciplinary Evaluation (CMDE) Provider Assurance Statement (DHS-7120A) (PDF) and proof you are qualified to provide EIDBI services including, but not limited to, licenses, certifications, college transcripts and diplomas.
QSP providers must submit the EIDBI Qualified Supervising Professionals (QSP) Assurance Statement (DHS-7120C) (PDF) and proof showing you are qualified to provide EIDBI services including, but not limited to, the following Advance Certification (when applicable), licenses, certifications, college transcripts and diplomas.
CMDE clinical trainee
Providers enrolling a mental health practitioner clinical trainee
Complete the EIDBI Comprehensive Multi-Disciplinary Evaluation (CMDE) Provider Assurance Statement (DHS-7120A) (PDF) to add mental health practitioner clinical trainee services to your existing Level I or II provider record.
Refer to the clinical trainee requirements on the Treatment Supervision and General MHCP Non-Enrollable Mental Health Provider Requirements webpages for more information.
Eligible providers to enroll as an EIDBI Individual Level I, II and III
Do not enroll as a Level I, II or III provider until your affiliated agency is actively enrolled with MHCP to provide EIDBI services.
EIDBI individuals can enroll or re-enroll with MHCP in one of the following two ways:
Use the Minnesota Provider Screening and Enrollment (MPSE) portal by following the instructions on the Organization to Individual Affiliations webpage or complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462.
Level I, II and III EIDBI providers
Enrollment requirements | Level I | Level II | Level III |
Required for fax submissions. This form is not required if you enroll through the MPSE portal. | Required for fax submissions. This form is not required if you enroll through the MPSE portal. | Required for fax submissions. This form is not required if you enroll through the MPSE portal. | |
Required for both fax and MPSE submissions. | Required for both fax and MPSE submissions. | Required for both fax and MPSE submissions. | |
EIDBI Provider Assurance Statements | EIDBI Level I Provider Assurance Statement (DHS-7120D) (PDF) -Required for both fax and MPSE submissions. | EIDBI Level II Provider Assurance Statement (DHS-7120E) (PDF) - Required for both fax and MPSE submissions. | EIDBI Level III Provider Assurance Statement (DHS-7120F) (PDF) - Required for both fax and MPSE submissions. |
Proof showing you are qualified to provide EIDBI services | The following may be required with your fax or MPSE submission depending on how you completed the Level I assurance statement: License, certifications, college transcript, diploma, or advance certification. | The following may be required with your fax or MPSE submission depending on how you completed the Level II assurance statement: License, certifications, college transcripts and diploma. | The following is required with your fax or MPSE submission depending on how you complete your Level III assurance statement: Certifications and diploma. |
Existing enrolled MHCP individual providers who are delivering EIDBI services
Providers do not need to enroll at multiple levels (for example, QSP and Level I). If you are changing between the different levels of EIDBI services, you must submit an updated EIDBI provider assurance statement and the applicable certification, license, transcript or other documents as noted on the assurance statement. Instructions for modifying the enrollment records of existing EIDBI individual providers in MPSE can be found on the Steps to Update an Existing Organization to Individual Affiliation guide.
Telehealth Services
All enrolled EIDBI individual providers that qualify and plan to deliver telehealth services must self-attest that they meet all conditions of the MHCP telehealth policy. Review the telehealth criteria on the EIDBI telehealth services webpage.
Level III EIDBI providers do not qualify to provide services via telehealth.
Individual providers should complete and submit the Provider Assurance Statement for Telehealth (DHS-6806) (PDF) to DHS through the MPSE portal or by fax to add telehealth services to your current enrollment record.
Reporting Changes
Fee-for-service members, lead agencies and other provider types use the Minnesota Health Care Programs (MHCP) Provider Directory and the Minnesotahelp.info directory to locate service providers in Minnesota. Your contact information is automatically added to these directories when you are approved to be an MHCP-enrolled CMDE provider or EIDBI agency. It is critical to keep your information updated to ensure efficient access to services.
All MHCP-enrolled providers (individuals and agencies providers) are required to notify Provider Eligibility and Compliance when a change occurs. Report any changes made on a provider record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment in the Enrollment with MHCP section under Provider Basics in the MHCP Provider Manual for details.
MHCP must be notified of changes in ownership 30 days before the sale or transfer of ownership.
Changes that occur before notifying MHCP, or missing or incorrect information, may result in billing suspension or termination per Minnesota Statutes, 256B.04, subdivision 21(d).
Revalidation
MHCP is required to follow the Centers for Medicare & Medicaid Services federal provider screening regulations.
MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all required forms and documents listed in the “How to enroll” sections to MHCP Provider Eligibility and Compliance at 651-431-7462.
We recommend using the MPSE portal and following the instructions on the Revalidation webpage in the MPSE user manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original Welcome Letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome Letter.
Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, about the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.
Processing Timelines
MHCP processes enrollment requests in the order received. MHCP will process the request and provide a response within 30 days. Responses include the following: pending for more information, approval and denial. If we need more information to complete your enrollment, we will send a request for more information letter via your MN–ITS mailbox or U.S. Postal Service telling you what you need to do to complete your enrollment. You will not be able to submit claims for services you provide until MHCP notifies you that your enrollment request is complete and approved.
If providers submit enrollment documents that are not complete or correct and MHCP Provider Eligibility and Compliance must request additional information or corrections, the provider must allow up to 30 days from the most recent date the materials were submitted for processing.
If MHCP approves your initial enrollment request, you will receive a Welcome Letter, including information about registering for MN–ITS. You must register for and use MN–ITS to receive mail from and submit electronic transactions to MHCP.
Report this page