HPE Toolkit: Forms and Documents

Overview
HPE Contact Information

HPE Frequently Asked Questions (FAQs)

HPE Toolkit – Forms and Documents
HPE Training

Forms and Documents

Refer to the following forms and documents for help with HPE:

  • Hospital Presumptive Eligibility Applicant Assurance Statement DHS-3887 (PDF)
  • Hospital Staff Who Passed DHS Hospital Presumptive Eligibility Online Training Course DHS-3889 (PDF). Hospitals use this form to submit the names and HPE Learning Center identification number of a minimum of two hospital staff who have passed the HPE training.
  • Unique Key Request Form

  • HPE Application

    Use the HPE Application DHS-3881 (PDF) to determine if the applicant qualifies for temporary Medical Assistance (MA) coverage with HPE. Applicants will also need to apply through MNsure for ongoing coverage.

    To help with completing the HPE application and making HPE eligibility determinations, hospital staff may refer to the following:

  • HPE Income and Household Size Worksheet DHS-3884A (PDF)
  • HPE Citizenship and Immigration Status Information Sheet DHS-7267B (PDF)
  • HPE Income and Asset Guidelines DHS-3884 (PDF)

  • Application

    Applicants for HPE will need to apply online through MNsure.org or fill out the paper Application for Health Coverage and Help Paying Costs DHS-6696 (PDF) for ongoing coverage.

    If you complete the paper DHS-6696 application for a person approved for HPE coverage, write “HPE” on top of the first page of the application. If the person approved for HPE is being discharged to an Institution for Mental Disease (IMD), write HPE IMD on top of the first page of the application. Fax the completed application to Health Care Eligibility Operations (HCEO) at 651-431-7780. 

    Some people may need to apply by completing a different paper application. If you complete any other paper application for Medical Assistance (for example, Minnesota Health Care Programs Application for Certain Populations DHS-3876 (PDF), Minnesota Health Care Programs Application for Payment of Long-Term Care Services DHS-3531 (PDF)) for a person approved for HPE coverage, submit the completed application to the applicant’s county human services agency for processing.

    Approval and Denial Notices

    Staff who need access to the HPE approval and denial notices must have MN–ITS user accounts. Each organization’s MN–ITS primary administrator must assign access to HPE Forms through MN–ITS User Administration for new and existing users who will be determining HPE.

    For HPE Approval and Denial Notices, log in to MN–ITS and select Hospital Presumpitve Eligibility from the left menu.

    Policies and Procedures

    The following documents and web page provide more information for hospital staff working with HPE applications:

  • Using MN–ITS to verify past coverage through HPE
  • HPE Policy Guide DHS-7267 (PDF)
  • HPE Procedures Guide DHS-7267A (PDF)

  • Training

    Refer to the following for specific training information:

  • Training basics
  • Unique Key request
  • HPE Learning Center

  • Other Resources

  • Provider News
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