Provider Record Review – Waiver/AC Program Services


November 19, 2012 – MHCP Provider Update WAV-12-01

Beginning mid-December 2012, MHCP will send letters to initiate a record review to all providers enrolled to provide services approved through the Home and Community Based Services (HCBS) Waiver or Alternative Care (AC) programs. MHCP will continue sending the requests through April 2013. This is to prepare for implementation of the new HCBS Waiver Provider Standards. Efficient record updates will help to avoid delays in payment and service authorizations upon implementation of the 245D license requirements effective January 1, 2014.

During this review, MHCP will require proof of licenses, certifications and assurance statements to validate qualifications for providing the applicable waiver service(s).

Record Review Requests

First, MHCP will send requests for record reviews to enrolled providers who are currently approved to provide services on an HCBS waiver or AC service authorization (SA). Next, MHCP will send requests to those enrolled to provide waiver/AC program services, but not currently providing services on an approved waiver or AC SA.

The request letter will have an option for providers to indicate they no longer choose to provide HCBS waiver and AC program services.

MHCP will place the request letter into the PRVLTR folder of the provider’s MN–ITS mailbox.

Consolidated NPI Records

If multiple service locations are consolidated under one NPI, MHCP will send only one request. The provider will be responsible to ensure enrollment documents are submitted for each individual location consolidated under that NPI. Submit documents only for locations providing HCBS waiver and AC program services.

Requested Documents

MHCP will request providers complete and submit all of the following documents for each of their waiver provider files to complete their record review:

  • • Waiver and AC Enrollment Application (DHS-4015)
  • • MHCP Provider Agreement (DHS-4138)
  • • Disclosure of Ownership Interest (DHS-5259)
  • • Assurance Statements – as appropriate
  • • Lead Agency Enrollment Request Form (DHS-6383) – as appropriate
  • • Proof of Licenses or Certifications – as appropriate

  • MHCP will update the Waiver and AC Enrollment Application (DHS-4015) with additional questions needed for the record review, and announce when the updated form is published and ready for use. Providers who submit information before the updated form is available will be required to resubmit the information on the updated form.

    New Assurance Statements

    MHCP developed new assurance statements to attest to qualifications for providing a specific service. Each new statement allows the provider to assure MHCP of actions they will take when providing the service, including assurance of background study requests for all direct care staff.

    Providers must complete and submit assurance statements during the record review to provide, or continue to provide, any of the following services:

  • • Assistive Technology
  • • AC Nutrition
  • • Behavioral Support
  • • Caregiver Assessment
  • • Caregiver Training and Education
  • • Chore Services
  • • Adult Companion Services
  • • Customized Living
  • • 24-hour Customized Living
  • • Emergency Response System
  • • Environmental Accessibility and Adaptations
  • • Family Caregiver Training & Education
  • • Family Training and Counseling
  • • Home Delivered Meals
  • • Homemaker
  • • Housing Access Coordination
  • • Independent Living Skills (ILS)
  • • Independent Living Skills (ILS) Therapy
  • • Night Supervision
  • • Personal Support
  • • Prevocational
  • • Respite
  • • Specialist
  • • Specialized Supplies and Equipment
  • • Structured Day
  • • Supported Employment
  • • Transitional Service
  • • Waiver/AC Transportation

  • For a complete list of these services and to view these assurance statements and other requirements, review Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638).

    Processing Requests

    MHCP will process documents in the order received. Providers must complete the record review by May 31, 2013. Non-compliance will result in either an end to a category of service or a terminated record effective July 1, 2013. Submit required information as early as possible after receiving the request letter to avoid any disruption in payment or approval of an SA.

    Upon completion of the review, MHCP will update the enrollment record and send a new enrollment letter to summarize the approved services on the provider record.

    Terminated Records

    While a provider’s record is terminated, or a category of services is ended, MHCP will not:

  • • Reimburse claims for the service(s) (even for services already approved on an SA)
  • • Approve any new services on an SA

  • Providers will continue to be responsible for proper notification to recipients when ending services according to their license or certification requirements or their contracts.

    Additional Resources

    MHCP Provider Enrollment – Waiver and Alternative Care (AC) Programs

    HCBS Waiver Providers Standards

    If you have questions about this information, call the MHCP Provider Call Center at 651-431-2700 or 1-800-366-5411.

    Sign up to receive Provider Updates and other MHCP notices in your email account.


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