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

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 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:

This page provides guidance to qualified supervising professionals (QSPs) on how to complete ITP and Progress Monitoring, DHS-7109.

The QSP must:

When completing DHS-7109, do not leave any fields blank. Use “N/A” if a field is not applicable.

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

In this section, indicate which type of ITP:

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

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

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

In section C, provide an overview of your treatment recommendations for the person, including:

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

In section C, also document how often the provider team will monitor the person’s progress.

You must base your 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, provide specific information about each service you request for authorization, including:

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 amount of units requested for each service in section D.

In section E, describe:

The information you collect in this section should help inform the person’s overall goal development in section G.

DHS recommends you complete and document a functional behavior assessment (FBA) if you use positive supports or restrictive procedures, or if you develop a behavior intervention plan to address interfering behaviors.

In section F:

If you do not complete an FBA, but you do note interfering behaviors in the ITP, include rationale for why you did not complete an FBA and how you will evaluate and address those behaviors throughout services.

In section G, define and describe the person’s targeted goals and objectives, as well as how the provider team will measure the person’s progress.

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:

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, identify specific objectives according to developmental domain. You do not need to include an objective for each domain.

For each applicable objective, document:

Note: DHS made updates to DHS-7109 to allow you to add as many goals as needed. Addendum B (DHS-7109B) is now obsolete.

Status

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

Indicate the rationale or data for the status selected. For more information, see the progress monitoring section.

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

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

In section I, document:

If a coordinated care conference did not occur, indicate the rationale for why you did not conduct one. For more information on coordinating with other services, see EIDBI – Coordination with other services.

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, document the person’s progress toward ITP goals and objectives during each update. In the person’s initial ITP, enter “N/A” in the progress monitoring section.

Adjusting the ITP based on progress monitoring

Based on the results of ITP progress monitoring, 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:

In the transition planning section, describe the plan to help the person and family to transition to other services, including:

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.

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 (see 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. Providers must ensure the person signing 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 the caregiver’s or guardian’s signature is required for service authorization.

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

Translated signature pages

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 is included in ITP and Progress Monitoring, DHS-7109.

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 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, see EIDBI – Services. For information about service termination, see EIDBI – Medical necessity.

If you have technical issues downloading the form, see DHS – Frequently asked questions about eDocs.

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 conflicts in scheduling.

When completing Addendum C, account for all of the 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, use a phrase such as “no activity scheduled” or “free time.”

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