Email: DHS.SIRS@state.mn.us. DHS-4159A Adult Mental Health Rehabilitative. MHCP funds paid for health care not documented in the health service record are subject to monetary recovery. FDR Compliance Program Requirements DHS will suspend or terminate any vendor who has been suspended or is currently under suspension or termination from participation in the Medicare program because of fraud or abuse. Abuse: In the case of a vendor, a pattern of practice inconsistent with sound fiscal, business, or health service practices, and that results in unnecessary costs to MHCP or in reimbursement for services not medically necessary, or that fail to meet professionally recognized standards for health services. endstream endobj 298 0 obj <>stream .D"NlI0kb`%*@Hnf`bd|r(A0@ '" Minnesota Statutes 256B.27 MA; Cost Reports UCare is a registered service mark of UCare Minnesota | 2023 UCare Minnesota. Restriction: In the case of a vendor, excluding or limiting the scope of the health services for which a vendor may receive a payment through a program for a reasonable time. If the enrollee does not respond with a health plan choice or a request to opt out, they will be defaulted into a plan. All program application forms can be found in eDocs. Minnesota Statutes 256B.48 Conditions for Participation DENC - Detailed Explanation of Non-Coverage Form Restricted Recipient Program Intake Form Birth Notification Form for Prepaid Medical Assistance Plan and MinnesotaCare member Prior Authorization Form for Early Intensive Developmental & Behavioral Intervention (EIDBI) They are typically utilized for things like requesting passports, visas, or social security numbers. DHS, at its own expense, may photocopy or otherwise duplicate any health service or financial record related to a health service for which a claim or payment is made under a MHCP program. 1; 256B.434). Forms for family child care Forms for licensed family child care providers This page has links to forms and documents for family child care providers. Fax: 651-431-7569 For more information, refer to the Nov. 29, 2022, eList announcement. Term a non-credentialed practitioner Change of Information TEMPORARY LICENSED AND LICENSED HOME CARE PROVIDERS . Consult with the appropriate professionals before taking any legal action. Notify MHCP Provider Enrollment in writing if you hire a billing agent after enrollment. "CYhpEObbG`aH??iQSj*{rfLbEdv va[?UZ.Nna!gI\ ,X]5 Microfilm records satisfy the recordkeeping requirements of this subpart and Minnesota Rules 9505.2175, subp. For assistance, refer to the Instructions to Complete the PCA Technical Change Request (DHS-4074A), DHS-4074C. Effective April 4, 2022, when a member is approved through a Provider Change Request, the eligibility start date with the new provider is the . UCare Individual & Family Plans Prescribing Privileges for PCP Partners 353 0 obj <>/Filter/FlateDecode/ID[<04A5E5A3A296AA409EDF09C9AB9EBE23><830E783FD1AAD44F879827D823D075FC>]/Index[294 123]/Info 293 0 R/Length 115/Prev 375273/Root 295 0 R/Size 417/Type/XRef/W[1 2 1]>>stream Minnesota Rules 9505.0315 Medical Transportation Requirements for Providers. The Department of Human Services (DHS) licenses certain Home and Community-Based Services (HCBS) provided to people with disabilities and those over age 65. UCare Contract Intake Form hb```f``~Ab,ukf550049(ox@)p4goD)'La8`t^@$/q S"GAz@[C#F `2(304)$00aa`bPe?Z$Q"Y.V N~&-`y8a+C -jTD4050~05=X:Q Care Management Referral Form - PDF Non-Dental Health Providers; Non-Pregnant Adults; Quick Intensive Developmental . MHCP Provider Enrollment reviews the provider's application and notifies the provider of its determination in writing within 30 days of receipt of the application. Interpreter Mileage Request Form endstream endobj startxref Minnesota Statutes 256B.02 Policy Disclosure of Ownership Form If Provider Enrollment terminates a provider, the provider has a right to an administrative appeal at the Office of Administrative Hearings (OAH). hZnGF"@^A3]9141sXoB56eg|l-5BM!dh"@5O[ >{t[tnCK&~h[Zd$cl 0k h| %d"@$4HOirh2-@B h&f@sSBs2904hfb<4MmF8`r)A BSBf[h0K 4S0EAs`HF[#=jK=&Z#0@Zu-fDdg?QH(S+lx2@-N Beginning on August 1, 2018, the provider may have to call the Office of Medical Assistance Programs, Provider Enrollment at 1-800-537-8862 to request a paper application if the PDF version of the application is no longer posted on the DHS Provider Enrollment website. Minnesota Statutes 246B.03 Definitions Out-of-state providers must comply with all terms of this section and follow laws of the state in which the provider is located. See additional requirements in Home Care Services and HCBS Waiver Programs and AC Program. CountyLink Other manuals This process is called a renewal. (DHS) Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) . Paper applications will continue to be accepted for processing. ! X&=@8 LBJv")Hs3pmS&M09&:*>.6)1!5%9#=-;+3/7 7/8(0,4$2"HWO_K[G]CSEUMQIYN^AZFVBRJTL\HX_@@ mN,Tp%N- \1* Interpreter Quarterly Report, Nursing Home Swing Bed Admission/Update Form Patient: Any adult resident, patient, recipient, or client receiving medical care from or through the provider. Federal law does not affect a provider's obligation to obtain informed consent to treatment. Change or update your facility profile(tax ID, legal name, ownership, address, phone, NPI) Subp. Download a fillable version of Form DHS-3535A-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services. This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. Forms utilized for the following codes: H2012, H2017, H0034, 90882, and H0019. Find DHS Forms Find a collection of the most popular forms across DHS: Immigration Forms, Travel Forms, Customs Forms, Training Forms, Additional Resources Immigration Forms Travel Forms Customs Forms Training Forms Additional Resources Keywords How Do I - At DHS How Do I? Consult with the appropriate professionals before taking any legal action. Searchable document library (eDocs) Online applications for individuals and families Health Service Records: In addition to those listed here, there may be other record obligations located throughout this manual specific to vendors of a particular service. Yes No Document in the patient's medical record whether the patient has executed an advance directive. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. DHS shall notify the vendor no less than 24 hours before obtaining access to a health service or financial record, unless the vendor waives notice. Program overviews. See the Enrollment with MHCP section for details about enrolling for each provider type. 0qPWp:dW5 ;6V]BpJ#@DE"?Fo=+57]>>=@^{"p5yM~'A}t`)6ts(T^ `p]~@5zPn/VO=RB;#Gkj@!bg~7s}f Many application forms are published in languages other than English and can be found through eDocs. They typically come in popular file formats, such as PDF or Microsoft Word, and are available for free or for purchase from websites and software providers. Minnesota Statutes 609.52, subd. As a professional or professionals delegate engaged in social services and the care of vulnerable adults, MHCP enrolled providers are mandated reporters under Minnesota Statute 626.557. Record retention under change of ownership. 7. MHCP also excludes individuals and entities from participation in MHCP if they are on either the federal or state excluded provider list. Send the notice to: DHS MHCP Provider Enrollment 0 This page provides quick links for providers looking for information, including how to enroll with MHCP and what services are covered. Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) - If you would like to begin receiving funds and remits electronically, complete the Provider Payment and Remittance Request Form within the UCare Provider Portal. Form DHS-3535-ENG Individual Practitioner - Mhcp Provider Profile Change Form - Minnesota. 4+t?1zxn nmZn5&xUAX5N(;a,r}=YUUA?z r[ $ If specific enrollment information is not listed for a provider type, see the enrollment webpage. Renewing MA eligibility. Printable templates are pre-designed documents or forms that can be easily printed and filled out by hand. Prior Authorization Form for Psychiatric Residential Treatment Facilities (PRTF) Care Management Referral Form - Word 0qPWp:dW5 ;6V]BpJ#@DE"?Fo=+57]>>=@^{"p5yM~'A}t`)6ts(T^ `p]~@5zPn/VO=RB;#Gkj@!bg~7s}f A provider shall render to recipients services of the same scope and quality as would be provided to the general public. Home health or personal care services providers. DHS Household CountyLink Get Manuals Home Bulletins . Minnesota Rules 9505 Health Care Programs j7v@i\yU-hB{n/x"ji7v2[Xf*Z&l>n+x^_?Fa.&& Driver and Vehicle Roster File 1114 0 obj <> endobj This website or its third-party tools use cookies, which are necessary to its functioning and required to achieve the purposes illustrated in the cookie policy. Minnesota Statutes 363A.36 Certificates of Compliance for Public Contracts Record retention in contested cases. 98 0 obj <> endobj Minnesota Statutes 256B.064 Sanctions; Monetary Recovery 42 CFR 431.107 Required provider agreement endstream endobj 1117 0 obj <>stream 10 states in part: "A provider shall not place restrictions or criteria on the services it will make available, the type of health conditions it will accept, or the persons it will accept for care or treatment, unless the provider applies those restrictions or criteria to all individuals seeking the provider's services. If the patient has an advance directive and has given the provider a copy, the provider must comply with the terms of the advance directive, to the extent allowed under state law. Using printable templates can save time and effort, as they provide a basic structure and design that can be used as a starting point for creating professional-looking documents. If you have questions, contact UCare's Provider Assistance Center at 612-676-3300 or toll free at 1-888-531-1493 or fill out the Facility Change Form - Demographic Change/Update by clicking here (Facility Change Form - Demographic Change/Update). endstream endobj 299 0 obj <>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 300 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream %%EOF . General Prior Authorization Request Form Department access to records. DHS 4695 Prior Authorization Fax Form . 181 0 obj <>/Encrypt 99 0 R/Filter/FlateDecode/ID[<973475DCD01E27468E832F0EBF960599><8141ECAA30294243A46EC116901FC5AF>]/Index[98 252]/Info 97 0 R/Length 200/Prev 547887/Root 100 0 R/Size 350/Type/XRef/W[1 3 1]>>stream The following are some commonly used forms for providers who work with UCare. 42 CFR 431.53 Assurance of transportation Minnesota Rules 9505.0225 Request to Recipient to Pay Minnesota Rules 9505.2195 Copying Records Add a non-credentialed practitioner NOMNC Valid Delivery Documentation Form endstream endobj 295 0 obj <>>>/MarkInfo<>/Metadata 24 0 R/Names 355 0 R/OCProperties<><>]/BaseState/OFF/ON[362 0 R]/Order[]/RBGroups[]>>/OCGs[361 0 R 362 0 R]>>/Pages 292 0 R/Perms/Filter<>/PubSec<>>>/Reference[<>/Type/SigRef>>]/SubFilter/adbe.pkcs7.detached/Type/Sig>>>>/StructTreeRoot 54 0 R/Type/Catalog/ViewerPreferences<>>> endobj 296 0 obj <>stream The following are some commonly used forms for providers who work with UCare. |/F0 J@ ,&I6*Xl{H)l@Ml)LcFFKJdD6 *,%Aq85,4Xi=gqiI/oo Hn0} The SASD Support Team will make every effort to process screening document deletion requests on a weekly basis. 42 CFR 455 Program Integrity: Medicaid TemplateRoller.com will not be liable for loss or damage of any kind incurred as a result of using the information provided on the site. 2. Recipient's consent to access. As of today, no separate filing guidelines for the form are provided by the issuing department. Medical transportation record must document: Medical supplies and equipment record must: Rehabilitative and therapeutic service records must comply with requirements listed in Rehabilitative Services. All MHCP enrolled providers must post a notice of nondiscrimination practices that is clearly visible in all of the following locations: The nondiscrimination notice must include all of the following information: For small publications or communications, such as postcards or tri-fold brochures, the nondiscrimination statement may contain no less than the following information: A nursing home is not eligible to receive Medical Assistance (MA) payments unless it refrains from requiring any resident of the nursing facility to use a vendor of health care services chosen by the nursing facility. (Minnesota Statutes 256B.02, 256B.433, 256B.48 subd. When that is not possible, the SASD Support Team will gather the information, research the issue and respond with an answer as soon as possible. HS]O0}_qd_TILXv]@O.K{=p> X1R)MD*u 7p\y D2a\&bh1hq{.uNj`)9T@*pU&T!Bz $2ToWIGtfN.[4y7n1MDP0j=g*E^ X2SYJsOJ=I!J]D]KRihmOS-f&nR#wa{:f$f? PCA Manual Clients must report changes to the designated provider 30 days before the change. Once the federal public health emergency ends on May 11, enrolled Housing Stabilization Services providers must come . Advance Directive: A written instruction such as a living will or durable power of attorney for health care, recognized under state law and relating to the provision of care when the patient is incapacitated. B) Unless otherwise provided by law, no provider of health care services will be declared ineligible without prior notice and an opportunity for a hearing under Minnesota Statute 14. (Minnesota Statute 256B.48, subd. TemplateRoller.com will not be liable for loss or damage of any kind incurred as a result of using the information provided on the site. Within DHS, the SIRS section is responsible for identifying and investigating suspected fraud, theft, and abuse. Genetic Testing Prior Authorization Form Referrals are made both to the Medicaid Fraud Control Unit (MFCU), and to the civil section of the AG's office. MHCP must make all payments to the provider. Title XI, section 1128(b) (formerly Title XIX, section 1909) of the Social Security Act )SI{ 0BO|cEs}Oq""TV}c`u-hSwi8J", St. Paul, MN 55164-0987 To protect private data and protected health information, lead agencies should contact the SASD Support Team using this secure form: Service Agreement and Screening Document (SASD) Support Team Portal, DHS-3754. "CYhpEObbG`aH??iQSj*{rfLbEdv va[?UZ.Nna!gI\ ,X]5 Top of Page. 1), Payment agreements between nursing homes and providers of ancillary medical care: A nursing home is not eligible to receive MA payments unless it refrains from requiring any vendor of medical care who is reimbursed by MA under a separate fee schedule, to pay any portion of the provider's fee to the nursing home. Withholding Payments: Reducing or adjusting the amounts paid to a provider to offset overpayments previously made to the provider. Suspending Participation or Suspension: Making a vendor ineligible for reimbursement through MHCP funds for a stated period. Housing Stabilization Services. endstream endobj 297 0 obj <>stream 46, and, additionally, Medicare. Provider Enrollment will notify the provider and ask for additional information if it is unable to make a determination. In addition, a nursing facility participating in the demonstration project may charge private pay residents up to the Medicare rate for the first 100 days after admission only if the private pay resident's stay is less than 101 days. Requirements regarding the need for a referral, or which days are available for treatment, etc., are legitimate requirements for MHCP recipients only if they are also applied to other clients. H\O07@Hc-&$@>DR{.Ch#kR:8L#Ic^%\\"o*I:`?8aJ M8 Minnesota Rules 9505.2175 Health Care Records SASD Support Team Portal, DHS-3754, 2023 Minnesota Department of Human Services, PCA Request Form (for lead agency use only), DHS-4292, Instructions to Complete the PCA Request (DHS-4292), DHS-4292A, Instructions to Complete the PCA Technical Change Request (DHS-4074A), DHS-4074C, MA Home Care Technical Change Request, DHS-4074, Instructions to Complete the MA Home Care Technical Change Request (DHS-4074), DHS-4074B, Service Agreement and Screening Document (SASD) Support Team Portal, DHS-3754, CBSM MMIS exception codes (formerly called MMIS edits), Nursing facility assessment for people age 64 and younger, Process and procedure: COR completes assessment for CFR, Reassessments when COR and CFR are different, Person-Centered, Informed Choice and Transition Protocol. PCA UMPI Add Form endstream endobj 302 0 obj <>/Subtype/Form/Type/XObject>>stream A vendor who commits any of the following acts may be convicted of a felony and fined up to $25,000 or imprisoned for up to five years, or both: Convicted: A judgment of conviction has been entered by a federal, state, or local court, regardless of whether an appeal from the judgment is pending, and includes a plea of guilty or nolo contendere. Minnesota Health Care Programs (MHCP) MA Home Care Technical Change Request Complete and fax this form to 6514317447 to request a technical change to an existing approved home care (nonPCA) service authorization for your agency. Documentation required for every child in family child care Documentation family child care license holders must maintain Additional family child care license holder forms and information If a vendor fails to allow DHS to use the department's equipment to photocopy or duplicate any health service or financial record on the premises, the vendor must furnish copies at the vendor's expense within two weeks of a request for copies by DHS. Although providers are not required by law to assist patients in formulating advance directives, providers may wish to have copies of the Minnesota Health Care Declaration (living will) form or the Durable Power of Attorney for Health Care form available for patients who request one. 1194 0 obj <>/Filter/FlateDecode/ID[<548F396191910F45BC1DEA5275CB9D4C>]/Index[1114 138]/Info 1113 0 R/Length 149/Prev 834614/Root 1115 0 R/Size 1252/Type/XRef/W[1 3 1]>>stream HQK0+.y+B")RaO m!n[d]{1|9s}Z2t6BIe)U$}C`u! The SASD Support Team makes every effort to process change requests and corrections within 10 business days. Non-participating Provider Claim Adjustment Form. Refer to these statutes for additional details of these provisions. Table of Contents; Member Find of Covers (EOC) MN-ITS User Quick; Minnesota Provider Screening press Enrollment Manual (MPSE) Latest revisions at this Manual; Provider Basics; COVID-19; Sedative Services; . Factor: An individual or organization that advances money to a provider for their accounts receivable for an added fee or a deduction of the accounts receivable worth. All requests sent to the SASD Support Team using DHS-3754 must include a contact name, email address, phone number, lead agency name, title, subject, description of the issue and Person Master Index (PMI) number. Lead agencies must send change requests by online form only using the PCA Request Form (for lead agency use only), DHS-4292. Ownership, Tax ID, and/or Legal Name change may require a new contract. 'u s1 ^ Inpatient hospitals, nursing facilities, providers of home health and personal care services, hospice programs and managed care plans are required by federal and state law to inform all adult patients about their rights to accept or refuse medical or surgical treatment, and the right to execute an advance directive. Furthermore, a provider who has such restrictions or criteria shall disclose the restrictions or criteria to DHS so DHS can determine whether the provider complies with the requirements of this subpart.". ADVERTISEMENT Download Form DHS-3535A-ENG Organization - Mhcp Provider Profile Change Form - Minnesota 4.3 of 5 (76 votes) Fill PDF Online Download PDF 1 2 3 Prev 1 2 3 Next According to federal law, the following providers must give written information on state laws regarding the patient's right to make decisions and the provider's policies concerning implementation of those rights at the following times: If a patient is incapacitated at one of the above times, and if the provider issues materials about policies and procedures to families, surrogates, or other concerned persons, the provider must include in those materials the information about advance directives. Combined Six-Month Report (CSR) (DHS-5576) (PDF). Refer to the MNITShome page for more information, system availability or to sign up to get email notices of changes. Provider: An individual, organization, or entity that has entered into an agreement with DHS for the provision of health services, including a personal care assistant. Statute references (with links to the Revisor's website) occur throughout this application (e.g., 144A.472). Durable Medical Equipment/Supply Prior Authorization Form FDR Attestation Minnesota Statutes 256B.0625 Covered Services ~S3(DD`@* UP=%w:T=2U3! Based on the type of request, also include the following information: SASD Support Team staff are available to reply to requests Monday through Friday, between the hours of 8 a.m. and 4 p.m. CBSM Home care overview Housing Stabilization is a Home and Community Based Service (HCBS), and providers of Housing Stabilization must abide by the HCBS requirements. HHA, SNV and HCN providers must send change requests for home care services by online form only using the MA Home Care Technical Change Request, DHS-4074. Minnesota Rules 9505.0140 Payment for Access to Medically Necessary Services You must be an MHCP-enrolled provider AND registered to use MNITS to access the system. H\t. The following practices are deemed to be abuse by a provider: Electronically Stored Data: Data stored in a typewriter, word processor, computer, existing or pre-existing computer system or computer network, magnetic tape, or computer disk. Specialty Referral Form DHS-4905C Extended Psychiatric Inpatient- Initial Review Site/Practitioner List Payment rates and special services for nursing homes and its private pay residents: A nursing home is not eligible to receive MA payments unless it refrains from requiring its residents to pay more than its MA rate for similar services. Form DHS-3535-ENG Individual Practitioner - Mhcp Provider Profile Change Form - Minnesota, Form DHS-5259-ENG Disclosure of Ownership and Control Interest of an Entity - Minnesota, Form DHS-0968-ENG Adoptive Applicant Registration - State Adoption Exchange - Minnesota, Form DHS-3371-ENG Direct Deposit for Your Child Support Payments - Minnesota, Form DHS-3887-ENG Hospital Presumptive Eligibility Applicant Assurance Statement - Minnesota, Form DHS-4633-ENG Home Health Certification and Plan of Care - Minnesota, Form DHS-4074-ENG Ma Home Care Technical Change Request - Minnesota, Form DHS-3868-ENG Adult Day Treatment Contract Cover Sheet - Minnesota, Form DHS-2518-ENG 72 Hour Report of Birth to Minor - Minnesota, Form DHS-7176H-ENG Hcbs Rights Modification Support Plan Attachment - Minnesota. 1). They must also submit a new Provider Agreement, a Disclosure of Ownership and Control Interest Statement for Participating Providers (DHS-5259) (PDF), and any other required enrollment documentation to Provider Enrollment no later than the effective date of the sale or transfer. A vendor shall grant DHS access during the vendor's regular business hours to examine health service and financial records related to a health service billed to a program. See complete requirements in the Enrollment with MHCP and the Excluded Provider Lists sections. Whether for personal or business use, they provide a cost-effective and convenient option for those who need to create and print multiple copies of similar documents. 42 CFR 447.10 Prohibition against reassignment of provider claims )SI{ 0BO|cEs}Oq""TV}c`u-hSwi8J", They authorize a post-payment review process to ensure compliance with MHCP requirements by monitoring the use of health services by recipients and the delivery of health services by vendors. Mental Health & Substance Use Disorder Case Management Referral Form hbbd```b``"H&;f &g/@$X!0 6lr(t sA. The latest edition provided by the Minnesota Department of Human Services; Compatible with most PDF-viewing applications. Minnesota Statutes 270C.40 Interest Payable to Commissioner Minnesota Statutes 256B.434 Alternative Payment Demonstration Project endstream endobj startxref UCare Individual & Family Plans Restricted Member Program Intake Form Section 504 of the Rehabilitation Act of 1973 This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. Universal Referral Form, Accident Reporting Form endstream endobj startxref This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. The notification must include the provider name, the National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI), office address, and billing agent's name and address. MHCP (Minnesota Health Care Programs): The Medical Assistance (MA) Program, MinnesotaCare, Behavioral Health Fund (BHF) Program, Prepaid Medical Assistance Program (PMAP), home and community-based services under a waiver from CMS, or any other DHS administered health service program. Information about the monitoring of recipient use of health services is found in Health Care Programs and Services. Form DHS-3535A-ENG Organization - Mhcp Provider Profile Change Form - Minnesota. Enroll with MHCP. 294 0 obj <> endobj All information is provided in good faith, however, we make no representation or warranty of any kind regarding its accuracy, validity, reliability, or completeness. %%EOF If you have Medical Assistance (MA) or MinnesotaCare, the Department of Human Services (DHS) must review your eligibility once a year to see whether you are still eligible. cy Lead agencies must allow all PCA/CFSS services agreements with edits that require DHS-level review to route to DHS for processing. PCA providers must send change requests by online form only using the PCA Technical Change Request, DHS-4074A. Designated providers are required to complete the Designated Provider section of DHS-3161 and fax the completed form to the county indicated on the form. Minnesota Statutes 256B.0644 Vendor Request for Contested Case Proceeding 177 0 obj <>/Filter/FlateDecode/ID[<63DF40A7DB4F1E41940627D0A3C8D7BD>]/Index[156 36]/Info 155 0 R/Length 105/Prev 166954/Root 157 0 R/Size 192/Type/XRef/W[1 3 1]>>stream 2. 1d, and means the sum of the following expenses incurred by a DHS investigator on a particular case: Medically Necessary or Medical Necessity: A health service that is consistent with the recipient's diagnosis and condition and: Ownership or Control Interest: Has the meaning given in Code of Federal Regulations, title 42, part 455, sections 101 and 102.