Penguin Health
Minnesota · Medical Assistance · EIDBI
Minnesota put EIDBI under prepayment review. The case note decides what pays.
After the largest autism-fraud case the Department of Justice has charged, Minnesota designated EIDBI high-risk, passed new licensure and supervision laws, and put EIDBI claims under prepayment review starting January 2026. The documentation standard is in the DHS EIDBI Benefit Policy Manual: seven case-note elements with payment-recovery teeth, and, since September 11, 2026, enumerated content for observation-and-direction notes. The matching rule set lives in the rules library in the Penguin Health app.
After EIDBI was designated high-risk in June 2025.
Including the date the documentation was added, unique among the states we cover.
The Observation and direction page revision, with a passive-observation exclusion.
One supervision hour per 16 direct treatment hours, per person.
The crackdown
What changed, and where the note decides it
The fraud cases were about services that never happened. The response lands on everyone else: prepayment review reads documentation before claims pay, new EIDBI agency licensure is rolling out through 2026, and the manual states that DHS "will recover payments made to the provider agency for EIDBI services that are not documented in the person's health service record." The case-note standard sits in the manual's Health service records page, under Minn. R. 9505.2175, and the observation-and-direction content was enumerated in the September 11, 2026 page revision.
- The person's name; the type of service; the name, title or level, and signature of the delivering provider; the date of service; the date the documentation was added; session start and stop times; and a summary of progress or response with any treatment or diagnosis changes.
- The specific program or skill observed as it relates to the ITP, the clinical observation and assessment, the direction or coaching given, and a data-informed rationale for any protocol modification with next steps.
- Passive observation without active engagement is not covered.
- A session has a pre-determined start and end time and ends at an unplanned break of 8 or more minutes or a non-ITP routine activity such as a nap, lunch, or bathroom routine.
- Since January 1, 2026: at least one hour of clinical supervision per 16 hours of direct treatment per person, and monthly observation and direction with at most two consecutive months via telehealth.
- O&D requires prior authorization and must not exceed 20% of direct intervention hours without individualized clinical rationale.
- EIDBI agency licensure rolls out through 2026: provisional applications from January, unlicensed agencies barred from June 1, decisions by year end.
The checklist
What a Minnesota EIDBI case note has to show
Each item below names its source and the Penguin rule that checks it. Minnesota sets no note-completion deadline; instead the note itself must carry the date the documentation was added, which makes lateness visible on its face.
| The note shows | What that means in practice | Source | Rule |
|---|---|---|---|
| The person's name and the type of service | Identity plus which EIDBI service this was (intervention, O&D, parent training). | Health service records | MN-1 |
| Provider name, title or level, and signature | The delivering provider signs with their level (QSP, level I, and so on). Only the deliverer's signature is required. | Health service records | MN-2 |
| The service date and the documentation-added date | Both dates on the note, with the service date matching the claim. | Health service records; 9505.2175 | MN-3 |
| Start and stop times matching the billing | Session times to the minute against the claim. | Health service records | MN-4 |
| A progress or response summary | How the person responded, with any treatment or diagnosis changes. | Health service records | MN-5 |
| O&D: the program observed, the assessment, the direction given | Tied to the ITP, with the clinical work shown. | O&D page, 9/11/26 | MN-6 |
| O&D: a data-informed modification rationale | When a protocol changes, the note shows the data behind it and the next steps. | O&D page, 9/11/26 | MN-7 |
| O&D: active engagement, not passive observation | A note describing only watching the session fails; the state does not cover it. | O&D page, 9/11/26 | MN-8 |
| No routine time inside the billed session | Naps, lunch, bathroom routines, and 8-minute breaks end the billable session. | Intervention page | MN-9 |
When multiple providers bill O&D simultaneously, each completes their own note documenting their distinct role.
The QSP submits a progress-monitoring update at least every six months on form DHS-7109.
Minnesota sets no note-completion deadline, so none is claimed. The documentation-added date on each note lets an organization set its own lateness threshold.
In the rules library
Nine Minnesota rules, ready to turn on
Open the rules library in the Penguin Health app, choose Minnesota EIDBI, and click Add to organization. Rules your organization already has are left alone, so adding the set twice only fills gaps. After adding, edit any rule or add your own alongside them.
Each rule runs only on notes billed to Minnesota Medical Assistance payers. Penguin checks the CentralReach payer name, and because EIDBI provider levels and code mappings vary by agency, the payer and code matches get confirmed against your real billing strings when the set is added.
Penguin reads signed session notes from CentralReach, read-only, after signature and before the claim, and runs the set on every note. Deterministic rules compare record fields. AI rules are read by the AI, which returns a pass or fail with a one-sentence reason.
Nine rules for EIDBI case notes: the seven required elements including the documentation-added date, the September 2026 O&D content, and session integrity.
- reviewed
- Oct 20, 2026
- runs on
- Notes billed to Minnesota Medical Assistance payers
- sources
- DHS EIDBI Benefit Policy Manual · Minn. R. 9505.2175
- watching
- The manual's Health service records and O&D pages (DHS blocks bots, so revisions are verified by hand against archived captures)
Every failure ships with QA guidance for that program code: an educational email, numbered action steps, and a QA email pre-filled with the date of service and a link to the note. Each reviewer action is written to a write-once audit log with seven-year retention, which is the record that answers a prepayment reviewer. Billing Medicaid in more than one state? The rules library covers sixteen, including Wisconsin and Missouri.
Maintained by Penguin
We watch DHS so the rules never go stale
Minnesota rewrote its O&D documentation standard in September 2026 while licensure was mid-rollout. The Minnesota set is tied to the manual pages, not to a template written once.
The EIDBI manual's Health service records and Observation and direction pages. DHS blocks automated fetching, so revisions are verified by hand against archived captures at each review.
We rewrite the affected rule, cite the page revision that changed it, and date the review. The set shows its sources and review date in the library.
An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, so a changed requirement shows you exactly which past notes it touches.
- EIDBI designated high-risk
Followed by new licensure, supervision, and anti-kickback laws.
- Prepayment review and the supervision minimum begin
EIDBI claims reviewed before payment; one supervision hour per 16 treatment hours per person.
- The O&D page is rewritten
Enumerated note content, a 20% share cap, prior authorization, and the passive-observation exclusion.
LibraryMN-6 through MN-8 are built against this revision.
- Minnesota set reviewed
Checked against the manual pages and Minn. R. 9505.2175. Current.
- WatchingLicensure decisions and the next page revision
EIDBI licensure decisions land by the end of 2026. When DHS revises the manual, the set is updated and every organization using it gets the change.
Next step
Run a month of EIDBI notes through Penguin
Bring one month of intervention and O&D notes. We add the Minnesota set from the rules library, run it, show every finding beside the manual page it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.