Minnesota Health Care Programs (MHCP) requires all enrolled providers to follow applicable state and federal regulations.
See the Enrollment with MHCP section for details about enrolling for each provider type.
The federal Health and Human Services–Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid and other federal health care programs. MHCP also excludes individuals and entities from participation in MHCP if they are on either the federal or state excluded provider list.
See complete requirements in the Enrollment with MHCP and the Excluded Provider Lists sections.
If a provider uses a billing agent or organization (person or entity that submits a claim or receives MHCP payment on behalf of a provider), the provider must also list the name and address of the billing agent on the enrollment application. Notify MHCP Provider Enrollment in writing if you hire a billing agent after enrollment. 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. Send the notice to:
DHS – MHCP Provider Enrollment
PO Box 64987
St. Paul, MN 55164-0987
MHCP must make all payments to the provider. However, MHCP may mail payment to a billing agent (such as an accounting firm or billing service) that furnishes statements and receives payments in the name of the provider if the agent's compensation for these services is any of the following:
MHCP pulls monthly reports to identify claims paid with dates of service on and after the effective date of the pay-to provider’s or rendering provider’s termination. MHCP will reprocess and reverse payments retroactive to six years following federal Required Provider Agreement regulations and Minnesota’s Covered Services rule that prohibits payment of a service to non-enrolled providers. Providers will see reversed claims as adjustments on their remittance advices.
An MHCP provider who sells or transfers ownership or control of a provider entity enrolled in MHCP must notify MHCP Provider Enrollment no later than 30 days before the effective date of the sale or transfer by submitting a Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF). MCHP may stop or withhold payments effective the date the sale or transfer takes place if the new entity’s enrollment is not complete.
A new owner of an entity enrolled in MHCP must complete and comply with all provider screening and enrollment requirements and conditions. 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. MHCP must process and approve the new entity owner’s enrollment before we can pay claims for services they provide.
DHS retains the right to pursue monetary recovery, or civil or criminal action against the seller or transferor.
If a new owner agrees to keep the NPI established for an entity (provider), as of the effective date of the sale or transfer of the provider the following apply:
Advance notification to MHCP Provider Enrollment is critical for providers of home care and waivered services due to the impact of a provider number change on service agreements through which they bill. See additional requirements in Home Care Services and HCBS Waiver Programs and AC Program.
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. Provider Enrollment will notify the provider and ask for additional information if it is unable to make a determination. If Provider Enrollment denies an initial provider enrollment application, the provider may not appeal the decision. If Provider Enrollment terminates a provider, the provider has a right to an administrative appeal at the Office of Administrative Hearings (OAH).
MHCP participation remains in effect until any of the following occur:
A provider who fails to comply with the terms of participation in the provider agreement or with requirements of the rules governing MHCP is subject to monetary recovery, Minnesota Rules, part 9505 program sanctions, or civil or criminal action. 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 Rules 9505.0195, subp. 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. A provider shall render to recipients services of the same scope and quality as would be provided to the general public. 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."
For example, providers cannot deny treatment for a certain diagnosis (for example, pregnancy) to MHCP recipients unless treatment for that diagnosis is also not available for other clients. 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.
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 Statute 256B.48, subd. 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. Exceptions to this are as payment for renting or leasing space or equipment or purchasing support services from the nursing facility. (Minnesota Statutes 256B.02, 256B.433, 256B.48 subd. 1)
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.
Exceptions are made for:
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. Refer to these statutes for additional details of these provisions. (Minnesota Statutes 256B.48, subd. 1; 256B.434)
Federal anti-fraud and abuse provisions prohibit certain types of business transactions or arrangements. A pertinent provision of these statutes is: Whoever knowingly and willfully offers; pays or solicits; or receives any compensation (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind:
The following practices are prohibited:
Offering or transferring remuneration to any individual eligible for benefits under this program, that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner or supplier any item or service for which payment may be made in whole or in part by this program. Examples of benefits include, but are not limited to such items as coupons providing discounts, cash, merchandise or other goods or services of value in exchange for utilizing services or obtaining goods from a particular provider.
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. Payment for any covered service furnished to a recipient by a provider may not be made to or through a factor, either directly or indirectly.
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. Out-of-state providers must comply with all terms of this section and follow laws of the state in which the provider is located.
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. The intent of an advance directive is to enhance a patient's control over medical treatment decisions.
Patient: Any adult resident, patient, recipient, or client receiving medical care from or through the provider.
Inpatient hospitals, nursing facilities, providers of home health and personal care services, hospice programs and managed care plans must maintain written policies and procedures as well as the following:
Providers are encouraged to work with associations and advocacy groups to further educate the community on these issues. Providers must be able to document their community education efforts.
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. Document in the medical record that the patient was unable to receive the information or was unable to articulate whether he or she has executed an advance directive. Once the patient is no longer incapacitated, give the information on advance directives to the individual. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Document in the patient's medical record whether the patient has executed an advance directive. 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.
Federal law does not affect the rights a provider may have under state law to object, based on conscience, to the treatment or withdrawal of an advance directive.
Federal law does not affect a provider's obligation to obtain informed consent to treatment.
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. The Minnesota Health Care Directive suggested form is found in Minnesota Statutes 145C.
As a professional or professional’s delegate engaged in social services and the care of vulnerable adults, MHCP enrolled providers are mandated reporters under Minnesota Statute 626.557. Under Minnesota law all enrolled providers are required to report all suspected maltreatment including abuse, neglect or financial exploitation of a vulnerable adult to the common entry point following the requirements in Minnesota Statutes 626.557, subd. 4.
MHCP providers are also mandated by law to report suspected maltreatment, abuse or neglect of children. Refer to child protection programs and services for more information. Report concerns about abuse or neglect to your county or tribal agency.
Minnesota Rules 9505.2160 to 9505.2245 (enacted June 10, 1991; amended March 18, 1995) establish a program of surveillance, integrity, review and control. 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. Within DHS, the SIRS section is responsible for identifying and investigating suspected fraud, theft, and abuse. SIRS is authorized to seek monetary recovery, to impose administrative sanctions, and to seek civil or criminal action through the office of Attorney General (AG). Referrals are made both to the Medicaid Fraud Control Unit (MFCU), and to the civil section of the AG's office. Information about the monitoring of recipient use of health services is found in Health Care Programs and Services.
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. 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.
Fraud: Acts which constitute a crime against any program, or attempts or conspiracies to commit those crimes including the following:
Health Plan: A managed care organization that contracts with DHS to provide health services to recipients under a prepaid contract.
Health Services: Goods and services eligible for MHCP payment under Minnesota Statutes 256B.02, subd. 8 and 256B.0625.
Health Service Record: Electronically stored data, and written or diagrammed documentation of the nature, extent, and evidence of the medical necessity of a health service provided to a recipient by a vendor and billed to MHCP.
Investigative Costs: Investigative costs are subject to the provisions of Minnesota Statutes 256B.064, subd. 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.
Pattern: An identifiable series of more than one event or activity.
MHCP (Minnesota Health Care Programs): The Medical Assistance (MA) Program, MinnesotaCare, Consolidated Chemical Dependency Treatment Fund (CCDTF) Program, Prepaid Medical Assistance Program (PMAP), home and community-based services under a waiver from CMS, or any other DHS administered health service program.
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.
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.
Suspending Participation or Suspension: Making a vendor ineligible for reimbursement through MHCP funds for a stated period.
Suspending Payments: Stopping any or all program payments for health services billed by a provider pending resolution of the matter in dispute between the provider and DHS.
Terminating Participation or Termination: Making a vendor ineligible for reimbursement through MHCP funds.
Theft: The act defined in Minnesota Statutes 609.52, subd. 2, clause (3)(c).
Third Party Payer: The term defined in Minnesota Rules 9505.0015, subp. 46, and, additionally, Medicare.
Vendor: The meaning given to "vendor of medical care" in Minnesota Statute 256B.02, subd. 7. The term vendor includes a provider and also a personal care assistant.
Withholding Payments: Reducing or adjusting the amounts paid to a provider to offset overpayments previously made to the provider.
Documentation: Health service records must be developed and maintained as a condition of payment by MHCP. Document each occurrence of a health service in the recipient's health record. MHCP funds paid for health care not documented in the health service record are subject to monetary recovery.
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. Records must contain the following information when applicable:
These vendors must follow additional requirements in their health service records:
Pharmacy service record must comply with Minnesota Rules relating to pharmacy licensing and operations and electronic data processing of pharmacy records. The pharmacy service record must be a hard copy made at the time of the request for service and must be kept for five years.
Medical transportation record must document:
Medical supplies and equipment record must:
Rehabilitative and therapeutic service records must comply with requirements listed in Rehabilitative Services.
Personal care provider records must comply with additional documentation requirements in the PCA section of this Manual.
Financial records, including written and electronically stored data, of a vendor who receives payment for a recipient's services under MHCP must contain:
Subpart 1. Recipient's consent to access. A recipient of Medical Assistance is deemed to have authorized in writing a vendor or others to release to DHS for examination according to Minnesota Statutes 256B.27, subd. 4, upon request, the Medical Assistance recipient's health service records related to services under a program. The Medical Assistance recipient's authorization of the release and review of health service records for services provided while the person is a Medical Assistance recipient shall be presumed competent if given in conjunction with the person's application for Medical Assistance. This presumption shall exist regardless of whether the application was signed by the person or the person's guardian or authorized representative as defined in Minnesota Rules 9505.0015, subp. 8.
Subp. 2. Department access to records. 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. Access to a recipient's health service records shall be for the purposes in Minnesota Rules 9505.2200, subp. 1. 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.
Subp. 1. Retention required, general. A vendor shall retain all health service and financial records related to a health service for which payment under a program was received or billed for at least five years after the initial date of billing. Microfilm records satisfy the recordkeeping requirements of this subpart and Minnesota Rules 9505.2175, subp. 3, in the fourth and fifth years after the date of billing.
Records may be maintained electronically in an Electronic Health Records (EHR) system for all or part of the five-year record keeping period. You must ensure that the electronically stored records meet all of the general record keeping requirements, including the ability for DHS to access and copy the records when required and any other requirement of Minnesota Rule 9505.2197.
Subp. 2. Record retention after vendor withdrawal or termination. A vendor who withdraws or is terminated from a program must retain or make available to DHS on demand the health service and financial records as required under subpart 1.
Subp. 3. Record retention under change of ownership. If the ownership of a long-term care facility or vendor service changes, the transferor, unless otherwise provided by law or written agreement with the transferee, is responsible for maintaining, preserving, and making available to DHS on demand the health service and financial records related to services generated before the date of the transfer as required under subpart 1 and Minnesota Rules 9505.2185, subp. 2.
Subp. 4. Record retention in contested cases. In the event of a contested case, the vendor must retain health service and financial records as required by subpart 1 or for the duration of the contested case proceedings, whichever period is longer.
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. Photocopying shall be done on the vendor's premises unless removal is specifically permitted by the vendor. 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.
If DHS permits use of installment payments, DHS shall assess interest on the funds, unless the overpayment occurred because of department error. The Department of Revenue establishes the rate under Minnesota Statute 270.75.
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.
If you suspect either a treating or rendering provider, or a provider group or agency, of fraud, abuse or improper billing, contact SIRS.
SIRS Hotline: 651-431-2650 or 800-657-3750 (anonymous)
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:
This does not apply to:
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.
Health Information Privacy – HIPAA
Minnesota Statutes 14 – Administrative Procedure
Minnesota Statutes 145C – Health Care Directives
Minnesota Statutes 62D.04, subd. 5 – Issuance of Certificate of Authority
Minnesota Statutes 256B.02 – Policy
Minnesota Statutes 246B.03 – Definitions
Minnesota Statutes 256B.04 – Duties of State Agency
Minnesota Statutes 256B.27 – MA; Cost Reports
Minnesota Statutes 256B.48 – Conditions for Participation
Minnesota Statutes 256B.0625 – Covered Services
Minnesota Statutes 256B.064 – Sanctions; Monetary Recovery
Minnesota Statutes 256B.0644 – Vendor Request for Contested Case Proceeding
Minnesota Statutes 256B.0655 – Authorization and Review of Home Care Services
Minnesota Statutes 256B.434 – Alternative Payment Demonstration Project
Minnesota Statutes 270C.40 – Interest Payable to Commissioner
Minnesota Statutes 363A.36 – Certificates of Compliance for Public Contracts
Minnesota Statutes 609.52, subd. 2 – Acts constituting theft
Minnesota Rules 9505 – Health Care Programs
Minnesota Rules 9505.0015 – Definitions
Minnesota Rules 9505.0070 – Third-Party Liability
Minnesota Rules 9505.0140 – Payment for Access to Medically Necessary Services
Minnesota Rules 9505.0170 to 9505.0475 – Medical Assistance Payments
Minnesota Rules 9505.0185
Minnesota Rules 9505.0195 – Provider Participation
Minnesota Rules 9505.0210 – Covered Services; General Requirements
Minnesota Rules 9505.0215 – Covered Services; Out-of-State Providers
Minnesota Rules 9505.0225 – Request to Recipient to Pay
Minnesota Rules 9505.0315 – Medical Transportation
Minnesota Rules 9505.0440 – Medicare Billing Required
Minnesota Rules 9505.2160 to 9505.2245 – Surveillance and Integrity Review Program
Minnesota Rules 9505.2175 – Health Care Records
Minnesota Rules 9505.2180 – Financial Records
Minnesota Rules 9505.2185 – Access to Records
Minnesota Rules 9505.2190 – Retention of Records
Minnesota Rules 9505.2195 – Copying Records
Minnesota Rules 9505.2197 – Vendor’s Responsibility for Electronic Records
Minnesota Rules 9505.2200 – Identifying Fraud, Theft, Abuse, or Error
Minnesota Rules 9505.5200 to 9505.5240 – Department Health Care Program Participation Requirements for Vendors and Health Maintenance Organizations
Section 504 of the Rehabilitation Act of 1973
Title XI, section 1128(b) (formerly Title XIX, section 1909) of the Social Security Act
Title XVIII, section 1877(b) of the Social Security Act
42 CFR 431.53 – Assurance of transportation
42 CFR 431.107 – Required provider agreement
42 CFR 447.10 – Prohibition against reassignment of provider claims
42 CFR 455 – Program Integrity: Medicaid
Stipulated Settlement Agreement Day v. Noot