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Authorization

Revised: 12-30-2016

  • MHCP Authorization Forms
  • Review Agents
  • Early Intensive Developmental and Behavioral Intervention Service Requests
  • Emergency Medical Assistance Care Plan Certification Requests
  • Emergency Medical Assistance Kidney Transplant Evaluation
  • Home Care Authorization Request
  • Out-of-state Services
  • Services Related to Investigational Drugs
  • MN–ITS Authorization Requests
  • General Authorization Criteria
  • Documentation Requirements
  • Authorization Requests and Medicare or TPL Coverage
  • Overview

    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 to fee-for-service MHCP recipients only for services other than drug authorizations. Refer also to the following information:

  • • Providers must contact the appropriate managed care organization for authorization requirements for recipients enrolled in prepaid health plans
  • • When recipients have private insurance, providers must follow authorization and other rules that apply to the primary insurance
  • • Review Drug Authorizations for requesting drug authorizations (do not send drug authorization requests to the medical review agent)
  • • An approved authorization does not guarantee MHCP payment; all other MHCP requirements must be met
  • Review Agents

    Submit authorization requests to one of the following review agents, based on the type of service requested:

  • MHCP (for the specific services listed in this section below)
  • Keystone Peer Review Organization (KEPRO) (medical review agent and Emergency Medical Assistance Care Plan Certification)
  • • Health Information Designs (HID) (refer to Drug Authorizations)
  • 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).

    MHCP

    Submit the following types of authorization requests directly to MHCP, following the instructions on the form(s):

  • Program HH Prior Authorization: Mental Health Services (DHS-5149) (PDF)
  • Nutritional Supplemental Authorization Request Form – Program HH (DHS-5849) (PDF)
  • Medication Therapy Management Services (MTMS) Authorization Form (DHS-6246) (PDF)
  • • Temporary home care service requests, following instructions on the Service Agreement Quick Reference Guide (PDF)
  • KEPRO

    Submit the following types of authorization requests to KEPRO, the medical review agent (select the type to learn more about how to submit):

  • Medical
  • Dental
  • Medical Supply
  • Inpatient Hospital
  • Early Intensive Developmental and Behavioral Intervention (EIDBI) services
  • Emergency Medical Assistance (EMA) Care Plan Certification (CPC) request
  • Home Care (except PCA and waiver)
  • Out of state services
  • How to Contact KEPRO
    Contact KEPRO by portal, fax, phone or U.S. mail as follows:

    Portal:

    mhcp.kepro.com.

    Contact KEPRO for access to the portal.

    Mail:

    KEPRO
    2051 Killebrew Drive, Suite 210
    Bloomington, MN 55425

    For authorization requests:

    For EMA Care Plan Certification requests

    Phone:

    612-354-5589
    866-433-3658

    Phone:

    844-810-1472

    Fax:

    866-889-6512

    Fax:

    844-472-3779

    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:

  • • Completed and signed authorization forms and supporting documentation to KEPRO
  • • Care Plan Certification requests and supporting documentation to KEPRO
  • • The MN–ITS response page and supporting documentation to KEPRO (if you submitted the initial request using the MN–ITS (278) Authorization Request).
  • 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

    Medical

  • 1. KEPRO portal (preferred): Enter the authorization request into the Atrezzo portal, and then electronically upload the required clinical support documentation.
  • 2. 278 transaction in MN–ITS: Write the assigned 11-digit number for the response pages on each page of your documentation and then fax or mail the required clinical support documentation.
  • 3. U.S. Mail: Mail the appropriate DHS authorization form with all required clinical support documentation.
  • Dental

  • 1. KEPRO portal (preferred): Enter the authorization request into the Atrezzo portal, and then electronically upload the required clinical support documentation including current digital x-rays.

    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.

    Medical supply

  • 1. KEPRO portal (preferred): Enter the authorization request into the Atrezzo portal, and then electronically upload the required clinical support documentation.
  • 2. 278 transaction in MN–ITS: Use the 278 transaction in MN–ITS. Write the response pages assigned 11-digit number on each page of your documentation and then fax or mail the required clinical support documentation.
  • 3. U.S. Mail: Mail the appropriate DHS authorization form along with all required clinical support documentation.
  • Inpatient hospital

  • 1. KEPRO portal (preferred): Enter the authorization request into the Atrezzo portal, and then electronically upload the required clinical support documentation.
  • 2. Phone: Initiate the request by phone, then fax or mail the required clinical support documentation.
  • 3. U.S. Mail: Mail the appropriate DHS authorization form along with all required clinical support documentation.

    Early Intensive Developmental and Behavioral Intervention (EIDBI) services

    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).

    Emergency Medical Assistance (EMA) Care Plan Certification (CPC) request

  • 1. KEPRO portal (preferred): Enter the EMA CPC request into the Atrezzo portal, then electronically upload the required clinical supporting documentation.
  • 2. Fax: Fax the EMA CPC request and clinical supporting documentation using the EMA dedicated fax line, 844-472-3779
  • 3. U.S. Mail: Mail the EMA CPC request and clinical supporting documentation.
  • Home Care (except PCA and waiver)

  • 1. KEPRO portal (preferred): Enter the authorization request into the Atrezzo portal, and then electronically upload the required clinical support documentation.
  • 2. 278 transaction in MN–ITS: Use the 278 transaction in MN–ITS. Write the response pages assigned 11-digit number on each page of your documentation and then fax or mail the required clinical support documentation.

  • Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Requests

    Effective July 1, 2015, KEPRO is the authorization review agent for all EIDBI authorization requests for the following services:

  • • EIDBI intervention (individual or group)
  • • EIDBI observation and direction
  • • Family or caregiver training and counseling (individual or group)
  • • Travel time
  • Use the secure web-based portal mhcp.kepro.com to submit the completed the Comprehensive-Multi-Disciplinary Evaluation (CMDE) Medical Necessity Summary Information (DHS-7108) (PDF) and Individual Treatment Plan (ITP) and Progress Monitoring (DHS-7109) (PDF) and any other required documentation. KEPRO has training available on how to complete an authorization request and upload documents using the portal.

    Emergency Medical Assistance (EMA) Care Plan Certification (CPC) Requests

    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 Kidney Transplants

    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:

  • • A prior authorization is required for the kidney transplant evaluation
  • • An inpatient hospital authorization is required for the kidney transplant
  • Detailed information on these requirements is available in the EMA Kidney Transplant Services section of this manual.

    Home Care Authorization Requests

    Effective April 1, 2013, KEPRO is the authorization review agent for all temporary and long-term authorization requests for the following home care services:

  • • Skilled nursing visits
  • • Home health aide services
  • • Private duty nursing 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.

    Out-of-State 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:

  • • The provider enrolls in MHCP and follows all program guidelines
  • • The services are medically necessary
  • • The services meet one of the following criteria:
  • • The services are provided in response to an emergency while the recipient is out of Minnesota or its local trade area
  • • The services are not available in Minnesota or its local trade area, and the attending physician has determined medical necessity and obtained prior authorization from the medical review agent. The county is responsible for travel expenses associated with obtaining the out-of-state services
  • • The services are required because the recipient's health would be endangered if he/she were required to return to Minnesota for treatment
  • Services Related to Investigational Drugs

    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.

    MN–ITS Authorization Requests

    To submit authorization requests using MN–ITS, follow the steps below:

  • • Complete and submit the Authorizations (278) transaction. After you submit your authorization request, you will receive an Authorization Response (278) with a unique number.
  • • Print the response.
  • • Write the unique number assigned from the Authorization Response on each document you will submit as supporting documentation, including any other authorization forms you may need to submit.
  • • Fax the supporting documentation (and additional authorization form, as appropriate) to the review agent.
  • 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.

    General Authorization Criteria

    MHCP requires authorization as a condition of MHCP payment if a health service, including a drug, meets one of the following:

  • • The health service could be considered, under some circumstances, to be of questionable medical necessity
  • • Use of the health service requires monitoring to control the expenditure of MHCP funds
  • • A less costly, appropriate alternative health service is available
  • • The health service is investigative or experimental
  • • The health service is newly developed or modified
  • • The health service is of a continuing nature and requires monitoring to prevent its continuation when it ceases to be beneficial
  • • The health service is comparable to a service provided in a skilled nursing facility or hospital but is provided in a recipient's home
  • • The health service could be considered cosmetic
  • Documentation Requirements

    Authorization review agents use the criteria listed below when processing authorization requests. Submit documentation demonstrating the requested service is:

  • • Medically necessary, as determined by prevailing medical community standards or customary practice and usage
  • • Appropriate and effective for the recipient's medical needs
  • • Timely, considering the nature and present medical condition of the recipient
  • • Provided by a provider with appropriate credentials
  • • The least expensive, appropriate alternative available
  • • An effective and appropriate use of MHCP funds
  • 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.

    Authorization Requests and Medicare or TPL Coverage

    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:

  • • An explanation of benefits (EOB) showing determination of payment by the primary payer(s)
  • • A determination of authorization or denial of authorization by the primary payer(s)
  • • Written communication from the primary payer(s) showing that the service is not covered for the recipient
  • • Documentation by the provider of a phone call to the primary payer(s) and the statements made by the primary payer about coverage of the service/item for the recipient.
  • • Documentation by the provider that, because of recent claim experiences with Medicare, coverage is not available for the service/item
  • 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.

    MHCP Authorization Forms

    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):

  • • ADA 2012 (dental claim form for dental authorization requests)
  • ARMHS and Day Treatment Authorization Form (DHS-4159A) (PDF)
  • Augmentative Communication Devices and Accessories Authorization Form (DHS-4535) (PDF)
  • Authorization Form (DHS-4695) (PDF)
  • Bath/Shower/Toileting Equipment Authorization Form (DHS-6008) (PDF)
  • CTSS Authorization Form (DHS-4159) (PDF)
  • Chiropractic Authorization Form (DHS-4878) (PDF)
  • Dental Implants Authorization Form (DHS-3538) (PDF)
  • Dialectical Behavior Therapy (DBT) – Additional – Authorization Form (DHS-6322A) (PDF)
  • Dialectical Behavior Therapy (DBT) – Initial – Authorization Form (DHS-6322) (PDF)
  • Enteral/Nutritional Authorization Form (DHS-3971) (PDF)
  • Enclosed Medical Beds Authorization Form (DHS-4370) (PDF)
  • MHCP Inpatient Hospital Authorization Form (DHS-4676) (PDF)
  • Mobility Devices Authorization Form (DHS-4315) (PDF)
  • Prosthetics and Orthotics Authorization Form (DHS-4437) (PDF)
  • Specialized Wound Therapy Authorization Form (DHS-4045) (PDF)
  • Standers and Accessories Authorization Form (DHS-4075) (PDF)
  • TMD Treatment Authorization Form (DHS-6119) (PDF)
  • Vision Therapy Authorization Form (DHS-4879) (PDF)
  • Notice of Action Taken

    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.

    Notice for Reconsideration

    If the review agent denies a request for authorization, the provider may submit one request for reconsideration. When requesting reconsideration, include the following:

  • • Additional documentation or an explanation why an exception should be made
  • • The original denial notice – it is not necessary to submit a new authorization request
  • Submit the reconsideration by fax or mail.

    Fair Hearings

    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.

    Legal References

    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

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