Skip To: Main content|Subnavigation|
Minnesota Department of Human Services MA Estate Recovery Manual
Advanced Search|  

Understanding Medical Assistance claims

III. MA claims payment histories

To determine the total amount of an MA claim, start by emailing DHS a completed Request for an MHCP Member’s Claims Payment History (DHS-2133) (PDF).

A. How to complete and submit a request for an MA claims payment history

Follow these steps to complete a request for an MA claims payment history.

1. Enter the MHCP member’s information under Step 1

Enter the MA member’s first, middle, and last name; date of birth; and eight-digit Member ID number (Person Master Index [PMI] number).

Please note: If you do not enter all eight digits of the PMI, including zeros, there will be a significant delay in the processing of your request.

2. Enter the date of your request under Step 2

Enter the date you email the request to DHS.

3. Indicate that your request is for MA estate recovery under Step 3

For MA estate recovery, do the following:

  • • Check the box that states “Request for Medical Assistance (MA) estate recovery.”
  • • Indicate whether the MA member has died.
  • • If the MA member has died, select “Yes” and enter the member’s date of death.
  • • If the MA member has not died, select “No.”
  • • Indicate whether the MA member lived or is living in a medical institution before the age of 55 by selecting “Yes” or “No.”
  • • This question is important because, if the member did live or is living in a medical institution before the age of 55, then you cannot collect unless DHS has an MA lien filed against the member’s real property.
  • • If the member did live or is living in a medical institution before the age of 55 and DHS does not have a lien in place, then to collect payment for services the member received before the age of 55, you must have the member’s treating physician, advanced practice registered nurse, or physician assistant sign a verification form stating that the member cannot be expected to return home from the medical institution.
  • • If the member ever returns to the community, then payment for services received before the age of 55 cannot be recovered.
  • • DHS is working to update its eDocs forms to provide local agencies with a method for receiving physician verification of permanent institutionalization outside the MA lien process.
  • Note: Step 3 has a second checkbox, which is for requesting a claims payment history for purposes other than MA estate recovery. When requesting a claims payment history for MA estate recovery, do not check this box or enter any data in the fields following it. Do not enter begin or end dates, major programs, or report types for MA estate recovery purposes.

    4. Enter your (requester’s) information under Step 4

    Enter your first name, last name, phone number, email address, and mailing address. Also enter your agency’s name and county code.

    5. Email the completed form or questions about the form to DHS at DHS.SRUfax@state.mn.us

    B. How to read an MA claims payment history

    After getting your request, DHS will send you the requested claims payment history. You may get up to three different reports: the standard report, the all-MA-payments report, and the pre–June 1994 report. Use the examples below for a reference. The examples have been redacted to comply with federal and state privacy law.

    1. The standard report

    The standard report provides you with a complete list of paid amounts for all recoverable services an MA member received at 55 years old or older, so long as the MA member was never a permanent resident in a medical institution and did not receive General Assistance Medical Care (GAMC) services before June 1994.

    The standard report provides paid amounts for the following services:

  • • MA long-term services and supports (LTSS)
  • • Nursing facility services (NFS)
  • • Home and community-based services (HCBS)
  • • Waiver HCBS
  • • Alternative Care (AC)
  • • Brain Injury (BI)
  • • Community Alternative Care (CAC)
  • • Community Access for Disability Inclusion (CADI)
  • • Developmental Disabilities (DD)
  • • Elderly Waiver (EW)
  • • Nonwaiver HCBS
  • • Home care nursing
  • • Home health aide services
  • • Medical equipment and supplies
  • • Physical therapy, occupational therapy, and speech therapy, when the service is provided by a home health agency
  • • Personal care assistance (PCA)
  • • Hospital and prescription drug services received during the time the member was provided NFS or HCBS
  • • GAMC services
  • The beginning of the standard report looks like this:

    DHS image

    The total claim amount appears at the end of the standard report. If the deceased’s case does not have any claim adjustments, the total claim amount appears in the far-right column of the “Grand Total” line:

    DHS image

    If the deceased’s paid amounts are adjusted, the total claim amount appears after the adjustments, over in the far-right column of the “Total Owed” line. An adjustment can add to or subtract from the Grand Total:

    DHS image

    Finally, the standard report separates paid amount subtotals for MA, AC, and GAMC services. In addition, paid amounts for MA may also be separated by certain MA eligibility types, such as MA-AX, MA-BC, or MA-NA. These separate subtotals become important when you enter your recovery in MMIS. The separation of an MA eligibility type subtotal on the standard report looks like this:

    DHS image

    Note about managed care paid amounts: If the letters “MCO” appear in the far-left “PayerSystem” column, those letters indicate that the amount shown in the far-right “Reimbursement Amount” column of the same line represents the part of the monthly capitation amount MA paid to a managed care organization (MCO) for the MA member’s coverage that is attributable to LTSS. In other words, because MA often pays recurring monthly amounts to MCOs for MCOs to provide MA coverage to MA members, that monthly amount must be adjusted through an actuarial formula so that, when an MCO covers LTSS, the full amount of the monthly amount MA paid to the MCO is not reported as the paid amount. Rather, a reduced percentage of the monthly amount that reflects how much LTSS cost is reported in the far-right column of the “MCO” line.

    DHS’ actuary, Milliman, in consultation with DHS, developed the actuarial percentages applied to managed care payments in the standard report. In developing the percentages, Milliman and DHS relied on Centers for Medicare and Medicaid Services (CMS) guidance, specifically, the CMS State Medicaid Manual, section 3810(A)(6), which states the following:

    If you [the State Medicaid Agency] have elected in your [Medicaid] State plan amendment to recover for some services covered under the State plan, but not all services, then you must recover from the individual’s estate that portion of the capitation payment that is attributable to the recoverable services, based on the most appropriate actuarial analysis determined by the State.

    Thus, because Minnesota recovers MA paid amounts for LTSS but not for all MA services received at 55 years old or older, the standard report produces the part of each monthly MCO payment attributable to LTSS in the “Reimbursement Amount” column.

    2. The all-MA-payments report

    You will get a report that includes paid amounts for all MA services (not just MA-LTSS) that an MA member received at any age during residence in a medical institution if the member:

  • • lived in the institution for six months or longer;
  • • was treated by a physician, advanced practice registered nurse, or physician assistant who certified in writing that the member could not reasonably be expected to be discharged and returned home; and
  • • died without being discharged from the institution and returning home.
  • The beginning of the all-MA-payments report looks like this:
  • DHS image

    The total claim amount appears at the end of the report after “REIMBURSEMENT AMOUNT.” It looks like this:

    DHS image

    3. The pre–June 1994 report

    Finally, if the deceased received GAMC services before June 1994, you will get the following report with the total claim amount appearing in the “RECIPIENT TOTAL REIMB AMT” line:

    DHS image

    Note:

    If the deceased received MA services at 55 years old or older before June 1994 and was in a nursing home at the time of services, you will be notified of the total recoverable amount of any MA or GM services after June 1994 and asked if you want to pursue any claims before June 1994. To pursue these claims, you must analyze each MA claim payment that appears on the pre–June 1994 report to determine whether the service falls under the definition of LTSS. DHS does not determine whether those MA paid amounts on the pre–June 1994 report are recoverable. That responsibility falls on you, and it is up to you to determine whether analyzing pre–June 1994 recoverable claims is a cost-effective use of county resources in each case.

    C. Final steps before asserting your final MA claim amount

    1. Review services listed on the claims-payment-history report(s)

    Review your claims-payment-history report(s) before asserting an MA claim amount to ensure that only recoverable services are included in the claim total.

    Payments for the following services are recoverable and should appear on the reports:

    MA: The following MA services:

  • • MA LTSS received at 55 years old or older:
  • • Nursing facility services (NFS)
  • • Home and community-based services (HCBS)
  • • Hospital and prescription drug services received during the time the member was provided NFS or HCBS
  • • All MA services received by a member, regardless of age, who permanently resided in a medical institution
  • GM: GAMC received at any age

    AC: AC services received on or after July 1, 2003

    The following services are not recoverable and should not appear on any claims-payment-history reports:

    AC: AC services received before July 1, 2003

    QM/SL/QI/QW: Medicare Savings Program (Qualified Medicare Beneficiary [QMB] program, Specified Low-Income Medicare Beneficiary [SLMB] program, Qualified Individual [QI] program and Qualified Working Disabled [QWD] program) services

    If any nonrecoverable services appear on a claims-payment-history report, subtract the claim amounts for those services from the total. Also, notify DHS that a nonrecoverable service appeared on a claims-payment-history report by emailing DHS at DHS.SRUfax@state.mn.us.

    2. If you got more than one report, add the claim totals from each report together

    The standard report: If no adjustments were made, use the “Grand Total” at the end of the report. If adjustments were made, use the “Total Owed” amount.

    The all-MA-payments report: Use the “REIMBURSEMENT AMOUNT” at the end of the report.

    The pre–June 1994 report: If the deceased received recoverable MA or GM services before June 1994, add individual claim amounts together using the guidance in section B.3 above.

    3. Subtract any AC premiums and any Medical Assistance for Employed Persons with Disabilities (MA-EPD) premiums that were billed to the member

    Subtract from the MA claim total any AC and MA-EPD premiums billed to the member during his or her life. This procedure has been included in previous policy bulletins, including Bulletin #15-25-05 for AC and Bulletin #15-21-08 for MA-EPD.

    First, determine whether the member received AC or MA-EPD, look up the member’s ID number in MMIS and check the “RELG” screen to see whether the member had eligibility type AC or DP. Use the examples below for a reference. The examples have been redacted to comply with federal and state privacy law.

    This is what AC coverage looks like on the RELG screen:

    DHS image

    This is what MA-EPD coverage looks like on the RELG screen:

    DHS image

    Second, if the member received AC or MA-EPD services, send an email to DHS requesting the premium payments using the format below:

    To: dhs.made@state.mn.us
    Subject:
    AC and/or MA-EPD Recovery – Payment History Request
    Body:
    Include the following:

  • • Member’s name
  • • Member’s PMI number and MAXIS case number
  • • Request for the total amount of monthly premiums paid by the client for AC or MA-EPD services (or both)
  • Third, wait for a response from DHS. When DHS emails the total premium amount paid, subtract it from the MA claim total. This figure is the final MA claim amount.

    D. Why you must use claims payment histories instead of PIN reports

    The Program Integrity Network (PIN) is a DHS data warehouse investigatory tool that is available to county fraud investigators and collection workers. It allows them to pull MA claims information out of the data warehouse. PIN information can be a starting point to figure out what went on in an estate recovery case and estimate the potential MA claim amount in a case.

    You can use a PIN report to find out whether a potential MA claim amount exists. If one does, you can then request a claims payment history from DHS. (You can always request a claims payment history without using PIN first.)

    However, a PIN report cannot tell you whether all claims contained in the data warehouse are collectible under estate recovery laws. The actual amount of the claim can be larger or smaller than the amount shown in the PIN report. All information obtained from PIN must be verified by a secondary source. You cannot collect on an estate using the claim amounts or claim total in a PIN report.

    Before beginning MA estate recovery, you must request a claims payment history from DHS. A PIN report may not be submitted to any party, to attorneys, or to the court.

    In summary, you can use a PIN report to investigate whether to begin estate recovery, but you may use only a claim total from a claims-payment-history report to recover on an estate.

    E. Why a claims payment history may provide a different MA claim total if you order a second history at a later date

    MA providers have up to one year from the date of service to bill DHS. In addition, amounts billed for MA services may be adjusted at a later date. Consequently, depending on the circumstances, if you order a second MA claims payment history for a deceased MA member at a later date, the MA claim total from the new reports may be different from what was previously reported. Change is the nature of the health care system. If circumstances demand that you order a second MA claims payment history, use the MA claim total from the new reports and revise your MA claim amount to the new total if you have already asserted the old MA claim amount in probate or elsewhere.

    Rate/Report this pageReport/Rate this page

    © 2017 Minnesota Department of Human Services Updated: 9/8/17 9:09 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 9/8/17 9:09 AM