Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Enrollment Criteria and Forms
Revised: August 29, 2025
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
Individuals with the following roles in providing EIDBI services are required to have a NETStudy 2.0 background study:
Individuals can only provide direct services after their study is complete and has resulted in a clearance (“eligible”) or set-aside of a disqualification 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 EIDBI Background Studies for more information.
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.
Agencies must include all staff and their BGS number on this form.
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 |
Required for fax submissions, but not for MPSE submissions. | |
Required for both fax and MPSE submissions | |
Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) | |
EIDBI Provider Agency Assurance Statement (DHS-7120B) (PDF) Must have an Advanced Certification holder affiliated to the EIDBI agency | |
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 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
Submit the EIDBI CMDE Provider Assurance Statement (DHS-7120A) (PDF) and proof you are qualified to provide EIDBI services including, but not limited to, a current copy of your license.
QSP Providers
Submit the EIDBI QSP Assurance Statement (DHS-7120C) (PDF) and proof showing you are qualified to provide EIDBI services including, but not limited to, a current copy of your license.
Note: Starting Jan. 1, 2025, an LBA can provide QSP services. If the level I EIDBI provider is enrolled as a QSP, the Services page in MPSE must include the Level I and QSP service. On the Credentials page, the provider must upload the LBA license using the Mental Health Professional credential. MPSE currently requires providers add the Transcripts and Master’s Degree or Doctoral Degree credentials, but these are not required for an LBA. To resolve these requirements, upload a blank document in place of those credentials to move forward.
CMDE clinical trainee
Providers enrolling a mental health practitioner clinical trainee
Complete the EIDBI 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.
All enrolling individual EIDBI providers must submit the following:
Depending on the level for which they are enrolling, EIDBI providers must also submit the following:
Level I EIDBI providers
LBA enrolling as a QSP
Level II EIDBI providers
Level III EIDBI providers
Modifying the enrollment records of existing EIDBI individual providers
If your qualifications have changed, submit an updated EIDBI provider assurance statement and the applicable certification, license, transcript or other documents as noted on the assurance statement. Find instructions for modifying the enrollment records of existing EIDBI individual providers in MPSE 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 qualifications of the MHCP telehealth policy. Review the telehealth criteria on the EIDBI telehealth services webpage.
Level III EIDBI providers do not qualify to provide EIDBI 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.
Individual provider profile changes
Change in ownership
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 the Revalidation section in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for more 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.
Risk Level for EIDBI Provider Agencies
All new enrollments, reenrollments, and ownership change requests submitted on or after June 1, 2025, will be screened at the high-risk level. These requests will also be subject to unannounced site visits and fingerprint background checks for all direct and indirect owners with 5% or more ownership. Providers undergoing revalidation on or after June 1, 2025, will also be screened at the higher risk level as part of the revalidation process according to Code of Federal Regulations, title 42, section 455.450.
Refer to the Risk Levels information on the Provider Screening Requirements section of the MHCP Provider Manual for more information.
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.
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