Provider Manual
Provider Manual
This evidence of coverage is for people who have fee-for-service coverage* through a Minnesota Health Care Program. An “evidence of coverage” explains your health care coverage and how to use it.
*When you have Minnesota Health Care Program coverage, you can get services in one of two ways: 1) you can be enrolled in a health plan and get services through that health plan, or 2) you can have fee-for-service coverage. Having fee-for-service coverage means that we pay a fee to our enrolled health care providers for a service they provide to you. This evidence of coverage is only for fee-for-service Minnesota Health Care Program members. Members who get services through a health plan should see the evidence of coverage for their health plan.
Table of contents
Welcome to membership in Minnesota Health Care Programs (referred to as MHCP). MHCP includes MinnesotaCare and all Medical Assistance programs. Not all programs cover all services. Call your worker or the Member Help Desk if you are not sure whether a service or item is covered.
MHCP (also “we,” “us” or “our”) is giving you this evidence of coverage, also called an EOC. An EOC explains your health care coverage and how to use it. This EOC includes the following:
Coverage is available in every county in Minnesota. If you want to find our enrolled providers, go to our MHCP Provider Directory.
When you have MHCP coverage, you can get services in one of two ways: 1) you can be enrolled in a health plan and get services through that health plan, or 2) you can have fee-for-service coverage, which means that we pay a fee to our enrolled providers for a service they provide to you. This EOC is only for fee-for-service MHCP members. Members who get services through a health plan should see the evidence of coverage for their health plan.
If you have questions or concerns, call our MHCP Member Help Desk. Member Help Desk hours of service are 8:00 a.m. to 5:00 p.m., Monday through Friday.
Phone number: 651-431-2670 or 800-657-3739
TDD/TTY: 711
If you do not agree with a decision we make, you have the right to appeal (example of a decision: a denial, reduction, suspension or termination of medical services). You have to ask for an appeal hearing in writing. You or someone who represents you must sign the request for an appeal. To request an appeal, fill out the Appeal to State Agency (DHS-0033) (PDF) form. For more information on appeals, go to our frequently asked questions about state appeal hearings.
Phone number: 651-431-3600 or 800-657-3510
TDD/TTY: 651-296-7385
Fax number: 651-431-7523
If you think a provider or another member is misusing MHCP benefits, MHCP payments or the system in general, please report this fraud. You do not have to give your name or contact information, but giving that information might help investigators if they have more questions. Go to our How to report fraud page to find examples of and report fraud by recipients, by child care providers or by health care providers. You can also contact the Office of Inspector General:
Phone number: 651-431-2650 or 800-657-3750
Form: Minnesota Fraud Hotline Form
If you have a hearing loss or speech disability, call the following numbers to access the resources listed in this EOC:
Each time you get health services, check to make sure the provider is enrolled with MHCP. Make sure you show your MHCP ID card at every visit.
If you need either a hearing interpreter or a spoken-language interpreter, let your health care provider know. You can also get an interpreter if you are the parent or guardian of a child patient who is under the age of 18. The provider cannot bill you for interpreter services.
Our approval is needed for some services to be covered. This approval is called a service authorization. Providers have to get the approval before we pay for the service or item and, in some cases, before you get the service or item. Providers have to get these authorizations so we can make sure the services or items are medically necessary for you and that you are getting the right amount of these services or items. Some services, such as chiropractic care, have limits. Chiropractic visits are limited to six per month or 24 per calendar year. If you need more visits, the chiropractor has to ask for approval through an authorization.
Some of the more common services and items that need authorization include the following:
The provider will send us documentation when asking for the authorization. After we review the documentation, your provider and you will get a letter letting you know whether the authorization was approved or denied. If the authorization was denied, you have the right to appeal that decision. Follow the process in the Appeal process section.
Having MHCP eligibility does not guarantee that certain services or items are covered. Some services, prescription drugs or medical equipment or supplies may not be covered. Read through the Covered services section in this EOC. You can also call the Member Help Desk with specific questions about coverage.
You may have to pay an amount toward the cost of some medical services. This is called cost sharing. Cost sharing consists of copays and a family deductible for certain services. See the main Cost sharing section below for more information.
We cannot pay you back for medical bills that you paid. State and federal laws prevent us from paying you directly. If you paid for a service that you think we should have covered, call the Member Help Desk.
You can get health services or items not covered by us if you agree to pay for them. Providers have to have you sign a form saying that you will be responsible for the bill before you get the service or item. Providers have to explain to you why the service or item is not covered and what services or items are covered that you could get.
If you choose to get services from a provider who is not enrolled with MHCP, you may be responsible for the cost of the services.
If you have other health or dental insurance, tell your worker right away. Tell your provider about the other insurance. Your provider will have to bill the other insurance before they bill us. If your provider does not bill the other insurance, we may try to collect from the other insurance.
If you have Medicare, you need to get most of your prescription drugs through the Medicare Part D plan. You have to enroll in Medicare Part D to get that prescription-drug coverage. We do not pay for prescriptions that are covered by Medicare Part D.
We and the health care providers who take care of you have the right to see information about your health care. When you enrolled in MHCP, you gave your consent for us to see this information. We will keep your information private according to law.
The Minnesota Restricted Recipient Program (MRRP) is a program for members who have not followed the rules for getting medical care or have misused services. If you are a restricted recipient or member, you may not pay out of pocket for services from providers to whom you are restricted.
You must get health services only from the provider or providers we designate (assign for you). You may be designated (assigned) one doctor, one pharmacy, one hospital or one other health service provider. You must remain in the MRRP for at least 24 months of eligibility for MHCP. You may be designated a home health agency or other providers. You may be prohibited from using the personal-care-assistance choice, flexible-use options or consumer-directed services. You will remain in the MRRP if you enroll in a health plan or change health plans. You will not lose eligibility for MHCP because you are in this program.
At the end of the 24 months, we will review your use of health care services. If you still did not follow the rules, you will be placed in the MRRP for an additional 36 months of eligibility. You have the right to appeal your placement in the MRRP.
You may be eligible for only Program HH or for other Minnesota health care programs and Program HH, such as Medical Assistance and Program HH.
The information in this EOC does not apply to people who are eligible only for Program HH and are ineligible for other Minnesota health care programs.
Go to Minnesota HIV/AIDS programs or Program HH Covered Services for more information about Program HH benefits.
After MHCP makes payments to providers for services they provided to you, you will get an explanation of benefits (EOB). The EOB will show the name of the provider or provider group we paid, the amount we paid and the dates of service. If you did not get services from the provider listed on the EOB, contact the DHS Fraud Hotline. (See the Phone numbers and contact information section of this EOC for the DHS Fraud Hotline number.)
Some services are confidential. EOBs do not show when we pay for the following services:
Call your worker to report these changes:
You do not have to give documentation for services to MHCP. The provider has to keep medical records of the services you get and the reason you get the services. If we need documentation, the provider will give it to us. The provider has to ask for authorization when it is required and bill us for services. We can pay only providers, not you.
Your fee-for-service coverage with us ends when you become ineligible for MHCP or when you enroll in a health plan. If you enroll in one of our prepaid health plans, the health plan will give you an evidence of coverage. You will have to follow the health plan’s rules and use the plan’s network of providers.
You may be able to get coverage for health care services you received in past months. This is called retroactive coverage. You can get retroactive coverage for several reasons, including these:
You must tell your health care providers as soon as possible when you receive retroactive eligibility for any reason.
Also see the Paying providers section above.
You are responsible for these things:
Each member gets his or her own MHCP Member ID card. It looks like one of the cards below. Always carry your member ID card with you.
Show your member card every time you see a provider. Also, show the cards for any other health coverage you have, such as Medicare or private insurance.
MHCP Member ID cards, March 2006 through present:
MHCP Member ID cards, January 2003 through February 2006:
MHCP Member ID cards issued before January 2003:
If you have an old card from before March 2006, ask your worker or the Member Help Desk for a replacement card. Older cards may have old phone numbers for members and providers.
Cost sharing refers to your responsibility to pay an amount toward your medical costs. Cost sharing includes copays and a monthly deductible.
If your income is at or below 100 percent of the federal poverty guidelines, you will pay no more than 5 percent of your monthly family income for cost sharing. This may reduce the copay amount to less than the amounts listed below.
The following members do not have to pay copays or family deductibles for medical services:
Some services never have copays and family deductibles applied to them. These services include the following:
The following services also do not have family deductibles applied to them:
The lists above are not complete lists. If you have questions about whether a copay or family deductible applies to a service, call the Member Help Desk at the phone number in the Phone numbers and contact information section.
Also, the following providers cannot charge copays to MHCP or family deductibles to American Indian members, regardless of whether the members are enrolled in a health plan:
Some services have copays. A copay is an amount you are responsible to pay your provider.
Fee-for-service copays |
Medical Assistance and other programs |
MinnesotaCare (when not enrolled in a health plan) |
|---|---|---|
Nonpreventive visit (such as for a sore throat, diabetes checkup, high fever, sore back, etc.) when services are provided by an advanced practice nurse, audiologist, chiropractor, doctor, nurse midwife, optician, optometrist, physician ancillary or podiatrist. These services include diagnostic procedures (such as a colonoscopy, endoscopy or arthroscopy). No copays are required for mental health visits. |
$3.00 |
$15.00 |
Emergency room visit when it is an emergency |
$0.00 |
$50.00 |
Emergency room visit when it is not an emergency |
$3.50 |
$50.00 |
Prescription drugs No copays are required for certain mental health or family planning drugs. |
$1.00 generic |
$6.00 generic |
Eyeglasses |
No copay |
$25.00 |
Inpatient hospital |
No copay or limit |
$150.00 per admission |
Outpatient hospital |
No copay |
$25.00 per visit |
Ambulatory surgery |
No copay |
$50.00 per surgery |
Radiology services |
No copay |
$25.00 per visit |
If you have Medicare, you have to get most of your prescription drugs through a Medicare prescription drug plan known as Medicare Part D. You may have different copays with no monthly limit for some prescriptions through Medicare Part D.
Pay your copay directly to your provider. Some providers may ask you to pay the copay when you arrive for the medical service. Other providers, like a hospital, may bill you after your visit. For example, a hospital may bill you for your nonemergency visit to the emergency room after the visit.
If you are enrolled in Medical Assistance and are unable to pay the copay, the provider still has to provide the service. This is true even if you have not paid your copay to that provider in the past or you have other debts to that provider. The provider may still bill you for the unpaid copays.
A family deductible is an amount adult family members have to pay each month toward health care costs. A deductible is separate from a copay. The family deductible amount is $3.10 per month in 2017. This amount is adjusted yearly.
MHCP does not cover:
See the specific services below for more information about covered and noncovered services.
This section describes the major services that MHCP covers. Most of the lists below are not complete lists of all covered services. Covered services must meet MHCP rules and guidelines. In general, for MHCP to cover a service, the service, according to leading community standards and usage, must be:
For covered services at a glance, refer to the MHCP Benefits Chart.
Some services have limits or need an authorization. Those services are marked with an asterisk (*).
Bariatric services are a covered service with authorization, doctor’s orders and a mental health evaluation. You may need to meet other specific conditions. Talk to your doctor about whether you meet the required conditions for this service.
Noncovered services include excess skin excision.
Acupuncture services are covered for the following:
Covered services include the following:
C&TC is a health care program of well-child visits for members under the age of 21. C&TC visits help find and treat health problems early. How often a C&TC visit is needed depends on age:
Covered services in C&TC preventive health visits include the following:
Covered services are as follows:
Noncovered services from a chiropractor include other adjustments, vitamins, medical supplies, therapies and equipment.
Covered services include the following:
Covered services are as follows:
Covered services include the following:
Noncovered services include artificial ways to get pregnant (artificial insemination, including in-vitro fertilization and related services; fertility drugs; and related services).
Early intensive developmental and behavioral intervention becomes a covered service as of July 1, 2015.
As of July 1, 2015, covered services are as follows:
As of July 1, 2015, noncovered services are as follows:
Covered services include the following:
Noncovered services include emergency care, urgent care and other health care services you get from providers located outside the United States.
In an emergency that needs treatment right away, either call 911 or go to the closest emergency room. Show your member ID card and ask to call your primary care doctor.
In all other cases, call your primary doctor, if possible. The doctor or nurse will tell you what to do.
If you are out of town, go to the nearest emergency room. Show your member ID card and ask to call your primary care doctor.
Covered services are as follows:
Noncovered services include the following:
Under federal and state law, family planning services are open-access services. “Open access” means you can choose any physician, clinic, hospital, pharmacy or family planning agency to get these services. You can get the family planning services in the first list below from any provider.
Some people are eligible for only family planning services and not any other services MHCP offers. Check with your worker or the Member Help Desk if you are unsure whether you are eligible for only family planning services.
Covered services are as follows:
Covered services are as follows:
Home and community-based waiver services are not covered service for MinnesotaCare members.
If you are a Medical Assistance member, you must be approved to get waiver services. Depending on the type of waiver you are approved for, the following are some services MHCP can cover with an approved authorization:
Home care services are a covered service under the following programs:
Covered services are as follows:
Covered services are as follows:
You must elect hospice benefits to get hospice services.
If you are under the age of 21 and getting hospice services, you can get services related to treatment of the terminal condition.
Covered services are as follows:
Noncovered services for inpatient stays include personal comfort items, such as TV, phone, barber or beauty services and guest service.
Covered services are as follows:
IEP services are available for members under the age of 21 if the services are specified in the IEP or individualized family service plan (IFSP).
Covered services include the following:
Covered services are as follows:
Interpreter services are available to help you get services. Face-to-face spoken-language interpreter services are covered only if the interpreter is listed on the Minnesota Department of Health’s Spoken Language Health Care Interpreter Roster.
Covered services include the following:
Noncovered services include the following:
You need a prescription or doctor’s order for medical equipment and supplies to be covered.
Covered services include the following:
Noncovered services include the following:
The following services are not covered but may be available through your county. Call your county for information.
You can get medication therapy management services to help you better understand and use your medications.
To get this service, you must:
You can get this service at a clinic or pharmacy. A pharmacist can monitor your medications and give you the training to get the best results from them.
The services listed below are covered and available in addition to the Medical Assistance or MinnesotaCare services and any waiver services you are eligible to receive. The services listed below can be delivered without affecting your waiver budget. MHM services are not meant to duplicate, take the place of or extend services that are already covered by your Medical Assistance or MinnesotaCare benefit set or your waiver benefit set. If a service is already available under your waiver, it is not available under MHM.
Covered services are as follows:
The following services are also covered, but only if you are not on a waiver:
Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table (PDF) for a complete list of MHM services and waiver interactions.
Nursing facilities are not a covered service for MinnesotaCare members.
If you are a Medical Assistance member, to be placed in a nursing facility, both of the following conditions must be met:
Covered services include the following:
Noncovered services include special services. Some members must pay their spenddown to the nursing facility.
Covered services are as follows:
PCA services are not covered services for MinnesotaCare members.
All PCA services for Medical Assistance members need to have approved authorization. You will receive a letter letting you know the amount of PCA services you can get. If we deny the services or you disagree with the amount of services you can get, you can appeal. See the Appeals section.
Covered services include the following:
Noncovered services include the following:
Covered services include the following:
Noncovered services include the following:
The drug has to be in our drug formulary. For a drug to be included in the drug formulary, the manufacturer must participate in the federal Centers for Medicare & Medicaid Services (CMS) drug rebate program.
You do not have to pay a copay for antipsychotic drugs used for the treatment of mental illness. You also do not have to pay a copay for drugs used for family planning or to help you stop smoking.
If a pharmacy person tells you the drug is not covered and asks you to pay, ask the person to call your doctor. Your doctor may need to prescribe a different drug that is covered. Your doctor may need to submit a special request, called a prior authorization, if your doctor thinks only a certain drug is right for you and that drug is not usually covered by your MHCP benefits. If the pharmacy will not call, you can call your doctor or the MHCP Member Help Desk.
Covered services include the following:
Noncovered services include the following:
Medicare pays for most of your prescription drugs through Medicare Part D. You have to enroll in a Medicare prescription drug plan to get most of your prescription drug services. You will get your prescription drug services through your Medicare prescription drug plan. You may have to pay a copay for prescription drugs covered by your Medicare prescription drug plan.
Covered services include the following:
Noncovered services include the following:
Covered services include the following:
Noncovered services include the following:
Covered services are as follows:
Organ and tissue transplants, including transplants of the following:
Transplant coverage includes the following:
A transplants must be done at a transplant center meeting United Network for Organ Sharing (UNOS) standards or a Medicare-approved transplant center. Stem cell transplant centers must meet standards set by the Foundation for the Accreditation of Cellular Therapy (FACT).
Covered services are as follows:
Noncovered services include the following:
For nonemergency medical transportation to the following services, because the services include transportation:
Urgent care is a covered service. An urgent condition is not as serious as an emergency. Urgent care is care for a condition that needs prompt treatment to stop the condition from getting worse. Urgent care is available 24 hours a day.
If you have other insurance, tell your worker before you get care. We will coordinate our payments with the other insurance. This is called “coordination of benefits.” Examples of other insurance include the following:
When you become an MHCP member, you agree to:
If your insurance changes, call your worker.
The following paragraph applies to some noncitizens:
You may have other sources of payment for your medical care. These sources might include another person, a group, an insurance company or another organization. If you have a claim against another source for injuries, we will make a claim for medical care we covered for you. State laws require you to help us do this. We may recover the claim from any settlement or judgment you receive from another source. This is true even if you did not get full payment of your claim. The amount of the claim will not be more than state laws allow.
The following paragraph applies to MHCP members, except some noncitizens:
You may have other sources of payment for your medical care. These sources might include another person, a group, an insurance company or another organization. Federal and state laws provide that MHCP benefits pay only if no other source of payment exists. If you have a claim against another source for injuries, we will make a separate claim for medical care we covered for you. Laws require you to help us do this. The claim may be recovered from any source that may be responsible for payment of the medical care we covered for you. The amount of the claim will not be more than federal and state laws allow.
If you disagree with a decision made by MHCP about a denial, reduction, suspension or termination of medical services, you can ask for a hearing. You have to ask for the hearing in writing. You or someone who represents you has to sign the request. You can request a hearing by filling out an Appeal to State Agency (DHS-0033) (PDF).
You have to ask for the hearing within 30 days after getting written notice of the decision. If you show good cause for not appealing within this time limit, you may appeal up to 90 days after the notice.
After we get your request, we will set a date for a hearing. We will tell you the exact date, time and place. The hearing might be in person or by telephone. You can call the human services judge and tell him or her that you want a face-to-face hearing if you have been scheduled for a telephone hearing. You can also call the human services judge and tell him or her that you want a telephone hearing if you have been scheduled for a face-to-face hearing. The human services judge may have to schedule the hearing for a different day and time.
If we are stopping or reducing a service, you can ask to keep getting the service if you file an appeal within 10 days after we send you the notice, or before the service is stopped or reduced, whichever comes later. The treating provider has to agree the service should continue. The service can continue until the appeal is resolved. If you lose the appeal, you may be billed for these services.
If you decide to file an appeal or ask for a hearing, it will not affect your eligibility for medical services.
Your provider may file an appeal or ask for a hearing on your behalf. You have to give the provider your written consent.
You can have a relative, friend, advocate, provider or lawyer help with your appeal or hearing.
There is no cost to you for filing an appeal with us.
If we are stopping or reducing your PCA services, you can ask to keep getting the same amount of services when you file an appeal. You have to file within 10 days of the date of the notice, or before the service is stopped or reduced, whichever is later. The services can continue until the appeal is resolved. If you lose the appeal, you may be billed for these services.
The following are the meanings of some words in this EOC.
Action: an action includes the following:
Anesthesia: Drugs that make you fall asleep for a surgery.
Appeal: Your written request to us for review of an action.
Autopsy: An examination of the body of someone who died. It is done to find out what caused the person’s death.
Chemical dependency: Using alcohol or drugs in a way that harms you.
Child: Members under the age of 21.
Child and Teen Checkups (C&TC): A special health care program of well-child visits for members under the age of 21. It includes screening to check for health problems. It also includes referrals for diagnosis and treatment, if needed.
Clinical trial: A qualified medical study test that:
Copay: An amount that you may have to pay to the provider for specific medical services. Copays are usually paid at the time services are provided.
Cost sharing: Amounts you may have to pay toward your medical care. Cost sharing amounts include deductibles and copays.
Covered services: The health care services that MHCP can pay for when conditions are met.
Durable medical equipment: Equipment that can withstand repeated use. It is used for medical purposes. The equipment has to be medically necessary and ordered by a doctor.
Emergency: A condition that needs treatment right away. It is a condition that a prudent person believes needs prompt care, and without prompt care, it could cause one or more of the following:
Labor and childbirth can sometimes be an emergency.
Evidence of Coverage: The name of the document you are reading. This document tells you what services we cover. It tells you what you have to do to get covered services. It also tells you your rights and responsibilities and ours.
Experimental service: A service that has not been proven to be safe and effective.
Family deductible: An amount that adult family members may have to pay each month toward medical services.
Family planning: Information, services and supplies that help a person decide about having children. Family planning decisions include choosing whether to have a child and choosing when to have a child.
Fee-for-service: A method of payment for health services. Under this method, the medical provider bills MHCP directly, and we pay the provider for the medical services he or she provided. This method is used when you are eligible for MHCP but are not enrolled in a prepaid health plan.
Hospice: A special program for members who are terminally ill and not expected to live more than six months. It offers special services for the member and his or her family.
Inpatient hospital stay: A stay in a hospital or treatment center that usually lasts 24 hours or more.
Investigative service: A service that has not been proven to be safe and effective.
Medically necessary: Appropriate for the condition. Medically necessary care includes care related to physical conditions and mental health. It includes the kind and level of service. It also includes the number of treatments. It includes where you get the service and how long it continues. Medically necessary care has to:
Medicare: The federal health insurance program for people 65 years of age or older. It is also for some people under the age of 65 with disabilities and people with end-stage renal disease.
Medicare Prescription Drug Plan: An insurance plan that offers Medicare Prescription Drug Program (Medicare Part D) drug benefits.
Notice of action: A form or letter we send you telling you about a decision on a claim or a service or about any other action taken by us.
Open-access services: Services for which federal and state law allows you to choose any physician, clinic, hospital, pharmacy or family-planning agency to provide them.
Outpatient hospital services: Services provided at a hospital or outpatient facility that are not at an inpatient level of care. These services may also be available at your clinic or other health facility.
Post-stabilization care: A hospital service needed to help a person’s condition stay stable after having emergency care.
Prescriptions: Medicines and drugs ordered by a medical provider.
Preventive services: Services that help you stay healthy, such as routine physicals, immunizations and well-person care. These services help find and prevent health problems. Follow-up care on conditions that have been diagnosed (like a diabetes check-up) are not preventive.
Primary care doctor or provider: The doctor or other health professional you choose to see for your routine care. This person manages your health care.
Provider: A health care professional or facility approved by state law to provide health care.
Service authorization: Our approval that is needed for some services before you get them.
Subrogation: Our right to collect money in your name from another person, group or insurance company. We have this right when you get medical services that are covered by us and by another source or third-party payer.
United States: For the purposes of this Evidence of Coverage, the United States includes the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Northern Mariana Islands.
Urgent care: Services you get for a condition that needs prompt treatment to stop the condition from getting worse. An urgent condition is not as serious as an emergency. Urgent care is available 24 hours a day.
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