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Minnesota Department of Human Services Prepaid Minnesota Health Care Programs Manual
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Managed Care
Prepaid Minnesota Health Care Programs Manual

The PMHCP manual contains the policies and procedures for the Prepaid Minnesota Health Care Programs which consist of:

Prepaid Medical Assistance Program (PMAP)
Prepaid MinnesotaCare Program (PMCRE)
Minnesota Senior Health Options (MSHO)
Special Needs BasicCare (SNBC)
Preferred Integrated Network (PIN)

Preface
Terminology

Acronyms

Introduction

  • Purpose
  • Authority
  • Federal Waivers
  • Design
  • MSHO
  • Project Administration
  • Department Administrative Responsibilities
  • County Administrative Responsibilities

  • Education and Enrollment

  • Education of Consumers
  • Education
  • Notification
  • MA Presentations
  • Assignment to a Managed Care Organization
  • Default MCO Assignment Process
  • Consumer Follow-up
  • Education for Non-English Speaking Consumers
  • Tracking System
  • Tracking Program
  • Eligibility to Enroll
  • Populations Included
  • Populations Excluded
  • PMAP Excluded Populations
  • MinnesotaCare Excluded Populations
  • Managed Care Key Dates
  • Managed Care Enrollment Cut-Off
  • Capitation
  • Managed Care Reinstatement
  • Procedures for Processing PMAP Enrollment Forms
  • Procedures for Processing MSHO Enrollment Forms
  • Procedures for Returned Mail

  • Changing MCOs

  • First Year Change Option
  • Open Enrollment
  • Open Enrollment Notification
  • Requirements for Mailing Open Enrollment Information to Enrollees
  • Open Enrollment Denials
  • MCO Changes outside Regular Enrollment Periods
  • Termination of MCO Contract
  • Other Change Options
  • Twelve Month Lock-In
  • Relocation of Enrollees
  • Denying a MCO Change Request

  • Coding Requirements

  • MCO Enrollment
  • Initial PMAP Enrollment
  • Reenrollment
  • MCO Codes
  • Exclusion Codes
  • Exclusion Hierarchy
  • MMIS Case Notes
  • MMIS Managed Care Panels
  • MMIS Managed Care Panels – RCHP
  • MMIS Managed Care Panels – REFM
  • MMIS Managed Care Panels – RENR
  • MMIS Managed Care Panels – RPPH
  • MMIS Managed Care Panels – RTRK
  • Additions to Open Cases
  • MMIS Managed Care Edits
  • Case Transfers
  • Adding a Newborn to an Open MA Case
  • Transitional Medical Assistance/Transition Year Medical Assistance
  • State Paid Medical Assistance (Major Program NM)
  • Hospitalization at Time of Enrollment

  • Disenrollment

  • RPPH Coding
  • Disenrollment Reason Codes
  • Disenrolling Excluded Enrollees

  • Reenrollment and Reinstatement

  • Reenrollment Procedures
  • Reinstatement Procedures

  • Adjustments

  • System Problems
  • Adjustment Process
  • Adjustments

  • State Reports

  • Reports to MCOs and Counties
  • Report Detail

  • Service Delivery

  • MCO Contracts
  • MCO Marketing
  • New Enrollee Materials
  • Changes in an MCO's Provider Network
  • Reporting of Newborns
  • Quality Improvement
  • Covered Services
  • Approval by MCO
  • Prescription Drugs and Over-the-Counter Drugs
  • Indian Health Service and Tribal Providers
  • Abortion Services
  • Care Management
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Child and Teen Checkups (C&TC) Program
  • PMAP Transportation Costs Covered by MCOs
  • MA Reimbursement for Transportation Costs by County
  • MinnesotaCare Reimbursement for Transportation
  • MinnesotaCare Inpatient
  • Second Medical Opinion
  • Copayments
  • Exclusions and Limitations of Service
  • Out-of-Network Services
  • Non-Covered Services
  • Authorization Prior to Payment
  • Transitional Services
  • Services to Nursing Facility Residents
  • MCO Coverage for Nursing Facility Services
  • Chemical Dependency (CD) Services
  • Court Ordered Treatment
  • Third Party Coverage
  • Coordination of Benefits
  • Education of Recipients Regarding Coordination of Benefits
  • Cost Effective Insurance
  • Provider Billing of PMAP Enrollees
  • Provision of Services for Incarcerated Persons
  • MA Eligibility and MCO Enrollment
  • MCO Coverage for IMD Services

  • Grievance, Appeal, and State Fair Hearing Process

  • Definitions
  • Notification Requirements
  • Role and Responsibility of County
  • Role of County
  • County Advocate Responsibility
  • County Advocate Involvement
  • MCO Internal Complaint Process
  • MCO Grievance Process
  • MCO Appeal Process
  • State Fair Hearing Process
  • Types of State Fair Hearings
  • Administrative State Fair Hearing of Mandatory Participation
  • Administrative State Fair Hearing to Change MCO
  • Service Related State Fair Hearing
  • Role of County Advocate
  • Role of Petitioner
  • State Ombudsman
  • Role of State Ombudsman
  • Responsibilities of Department Ombudsman
  • Relationship between the MCO and the Ombudsman

  • Data Privacy

  • Compliance
  • Privacy Rights Statement
  • Confidential Data
  • Enrollee Eligibility Verification
  • Release of Information
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