HPE Toolkit: Forms and Documents
Forms and Documents
Refer to the following forms and documents for help with HPE:
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:
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:
Refer to the following for specific training information: