Some MHCP covered services require authorization. The authorization requirement is used to safeguard against inappropriate and unnecessary use of health care services governed by state law and federal regulations. Information in this section pertains only to fee-for-service MHCP members for services other than drug authorizations. See separate section for details about drug authorizations. Refer also to the following information:
Submit authorization requests to one of the following review agents, based on the type of service requested:
For information about specific services requiring authorization and documentation requirements, refer to the appropriate covered services section of the MHCP Provider Manual, Provider Home web page, or the MHCP Fee Schedule (fee schedule does not indicate documentation requirements).
Submit the following types of authorization requests to KEPRO, the medical review agent (select the type to learn more about how to submit):
How to contact KEPRO
Contact KEPRO by portal, fax, phone or U.S. mail as follows:
Contact KEPRO for access to the portal.
For authorization requests:
For EMA Care Plan Certification requests
How to use the KEPRO provider portal (Atrezzo)
Enrolled providers may access the KEPRO secure web-based portal at mhcp.kepro.com. Use the portal to upload the following documents:
Note: When you use the KEPRO Provider Portal to submit the initial authorization request, you do not have to submit using MN–ITS.
How to submit authorization requests to KEPRO
Depending on the type of services, submit authorization requests to KEPRO using one of the options listed in this table:
Type of request
How to submit
For non-digital x-rays, mail a current copy of the x-rays with the Atrezzo case number listed to assure accurate processing.
2. 278 transaction in MN–ITS: Write the response pages assigned 11-digit number on each page of your documentation and on the x-rays and then fax required clinical support documentation and mail a current copy of x-rays.
3. U.S. Mail: Mail the appropriate ADA 2012 Dental Claim authorization form along with all required clinical support documentation and a current copy of the x-rays.
3. U.S. Mail: Mail the appropriate DHS authorization form along with all required clinical support documentation.
KEPRO portal (required): Enter the authorization request into the Atrezzo portal. The required information is in the EIDBI service authorization request section of the Individual Treatment Plan (ITP) form. Electronically upload the completed Comprehensive Multi-Disciplinary Evaluation (CMDE) (DHS-7108) and Individual Treatment Plan (ITP) (DHS-7109).
Effective July 1, 2015, KEPRO is the authorization review agent for all EIDBI authorization requests for the following services:
Use the secure web-based portal mhcp.kepro.com to submit the completed Comprehensive-Multi-Disciplinary Evaluation (CMDE) Medical Necessity Summary Information (DHS-7108) (PDF) and Individual Treatment Plan (ITP) and Progress Monitoring (DHS-7109) (PDF), including any other required documentation. KEPRO has training available on how to complete an authorization request and upload documents using the portal.
Effective June 1, 2016, KEPRO is the medical review agent for all EMA CPC requests.
Use the secure web-based portal (mhcp.kepro.com) to upload and submit the EMA CPC request and required clinical supporting documentation. KEPRO has training available on how to upload documents using the portal.
Fax CPC requests and documentation to the dedicated EMA fax number if you do not have access through the secure web-based portal.
EMA provides coverage for kidney transplants to eligible recipients who are currently receiving dialysis as of July 1, 2016, through an approved EMA CPC. The following are also required:
Detailed information on these requirements is available in the EMA Kidney Transplant Services section of this manual.
Effective April 1, 2013, KEPRO is the authorization review agent for all temporary and long-term authorization requests for the following home care services:
Use the secure web-based portal (mhcp.kepro.com) to upload documentation and submit requests. KEPRO has training available on how to upload documents using the portal.
Submit requests using the MN–ITS DDE Authorization Request (278) transaction only if unable to use the KEPRO portal. Use the Authorization Requests (278) – Home Care MN–ITS User Guide for instructions.
Fax or mail documentation if you do not have access through the secure web-based portal.
Submit all documentation for long-term home care authorizations directly to KEPRO. Do not send requests to DHS. MHCP will not process or forward any documentation requests received on or after April 1, 2013. MHCP will continue to process PCA requests and technical change requests for home care services.
Except for emergency services, providers rendering health care services to MHCP recipients outside Minnesota or its local trade area must obtain authorization before providing MHCP-covered services. Out-of-state providers who do not see the recipient but provide health care service (such as lab or medical supply) do not need to obtain authorization unless the services would otherwise require authorization.
MHCP-covered services provided to a Minnesota recipient at a location outside of Minnesota or its local trade area by an out-of-state provider will be covered under the following circumstances:
MHCP does not cover costs incidental to, associated with, or resulting from the use of investigational drugs, biological products, or devices as defined in the Minnesota Right to Try Act. Authorization is not available for these services.
To submit authorization requests using MN–ITS, follow the steps below:
Allow 10 business days for the review agent to process prior authorizations, and 30 business days for retroactive authorization reviews. The MHCP Call Center cannot determine status of pending authorizations.
MHCP requires authorization as a condition of MHCP payment if a health service, including a drug, meets one of the following:
Authorization review agents use the criteria listed below when processing authorization requests. Submit documentation demonstrating the requested service is:
Some services and procedures require additional documentation. Refer to the appropriate provider type section(s) for more information about specific documentation requirements, or contact the medical review agent or HID, as appropriate.
If a modifier is required for a particular procedure code, include the appropriate modifier in the authorization request.
Information on the authorization request, including the procedure code(s) and the modifier(s), must match the information on the claim you submit for the service(s), or MHCP will deny the claim.
Bill services with approved authorization on a separate claim from services not authorized.
Except for home care authorization requests, MHCP will not consider a request for authorization of a service or item for a recipient with Medicare or TPL unless the provider has made a good faith effort to receive authorization or payment from the primary payer(s).
For services or items, document and submit to the review agent the good faith effort with any of the following:
Except for home care authorization requests, authorization is not required if a third party payer has made payment that is equal to or greater than 60% of the MHCP maximum allowed amount for the service or item. Submit the claim to MHCP and attach the EOB from the other payer(s) to the claim. See also Medicare and Other Insurance.
The review agent accepts the following paper forms for authorization requests (some forms are in addition to the MHCP Authorization Form; see instructions on the forms):
The review agent or MHCP will send written notification to the provider and recipient of action taken on an authorization request. The review agent will notify the provider if they need additional information to decide medical necessity. If the review agent denies a request, the recipient will receive a notice of recipient's right to appeal.
If the review agent denies a request for authorization, the provider may submit one request for reconsideration. When requesting reconsideration, include the following:
Submit the reconsideration by fax or mail.
If the review agent or MHCP deny or reduce an authorization, the recipient may appeal (see Your Appeal Rights (DHS-1941) (PDF)) the decision within 30 days, or within 90 days with good cause, and receive a hearing before a referee from DHS. To request a hearing, the recipient must contact the county agency or the Appeals Unit at DHS.
Providers do not have the right to appeal a denied authorization request under the MHCP fair hearing process. Providers may submit additional documentation and ask the medical review agent for a reconsideration of a decision.
Minnesota Statutes 151.375 – Right to Try Act
Minnesota Statutes 256B.02 – Definitions
Minnesota Statutes 256B.04 – Duties of state agency
Minnesota Statutes 256B.0625 – Covered services
Minnesota Statutes 256B.0625, subd 25b – Authorization with third-party liability
Minnesota Statutes 256B.0625 subd. 64 – Investigational drugs, biological products and devices.
Minnesota Rules 9505.0175 – Definitions
Minnesota Rules 9505.0215 – Out-of-state providers
Minnesota Rules 9505.0501 to 9505.0545 – Establish admission certification standards and procedures
Minnesota Rules 9505.5000 to 9505.5105 – Establish authorization procedures