Work with claims data
Page posted: 8/3/26
This page includes information about:
Claims subsystem overview
The claims subsystem in MMIS processes payment of health care claims for services provided through public health care and other programs. All other subsystems in MMIS work to support appropriate claims payment. The claims subsystem uses data in the most current recipient, provider, prior authorization and reference files to edit, audit and process claims.
Providers submit claims electronically through MN–ITS. The claims subsystem assigns a unique 17-digit payer claim control number (PCN) to all submitted claims. The PCN provides a method to identify any claim in the system. For more information, refer to How to Read the PCN, DHS-3948B (PDF).
Retention
The claims subsystem maintains 36 months of claims history for auditing, online inquiry and reporting purposes. You can view claims history using inquiry if you have MMIS security access to this subsystem.
Claims adjudicated (i.e., processed) before the 36-month retention period are stored permanently on the archived claims file.
Exception codes (i.e., edits) and errors
MMIS suspends a claim with errors and places it in the claims file so DHS staff can attempt to resolve the claim exception codes. MMIS denies claims if DHS cannot resolve the problems.
Once in the system, all claims are subject to a complete series of exception codes and audits to ensure only valid claims for eligible people and covered services are paid at appropriate rates to enrolled providers.
Exception codes for claims include data validity, recipient, provider, reference, rates, duplicate checking and utilization review auditing.
Billing process and payment
Providers bill for all HCBS services on a per-day basis, except for consumer directed community supports (CDCS-T2028) and personal emergency response systems (PERS-S5161). MMIS will not accept claims that use a “from/through” date on the claim. The service agreement line items may continue to authorize services based on a from/through period.
Claims process daily using various pricing methodologies to accommodate the many claim types. MMIS will adjust the amount paid based on the applicable spenddown, copay or third-party payment as recorded in the person’s recipient file.
Claim payment cycles typically occur on a bi-weekly basis. Every provider with claim activity in a payment cycle receives a remittance advice (RA) organized primarily by claim type. The RA includes:
Claims must be submitted and in a status of “to be paid” or “paid” within 365 days of the service date. Otherwise, the claim will be denied.
Residential absences for customized living service or foster care
Claims for residential services cannot include days and units for residential absences. Residential absences are days when the person is not receiving residential services and is not in the residential setting. Examples of residential absences include days for:
Payment in full
A provider must accept reimbursement as payment in full for covered services they provided to a person. This means a provider may not request or accept payment from a person receiving services, their family, the local human service agency or any other source in addition to the amount allowed under the programs. Exceptions for this rule include when there is a waiver obligation, spenddown or other payment (e.g., insurance) the person receives that is designated for the service. In this case, the provider bills the person directly for the payment (or the portion of the payment) that is the person’s responsibility.
Eligibility Verification System (EVS)
EVS is a touch-tone automated telephone service that provides eligibility information for each person. Before submitting a claim, DHS encourages providers to contact EVS to verify the person’s eligibility once per month at:
HCBS claims payment and service agreements
Claims for services provided through waiver, Alternative Care (AC), Essential Community Supports (ECS) and Moving Home Minnesota (MHM) programs pay against approved line items on a service agreement. No claims pay against a line item with a status of suspend, pend or deny.
When a provider submits a claim for payment, MMIS checks the following information on the service agreement:
1. Does the authorization number on the claim form match a service agreement authorization number?
2. Does the claim line item match a service agreement line item’s provider number, procedure code and dates?
3. Does the line item have a status of approved?
4. Does the rate on the claim exceed the rate on the service agreement line item?
5. Does the service agreement line item have enough units or total amount to cover the claim?
CDCS service agreements and claims
MMIS LTSS Manual – CDCS claim payments includes information about authorization, billing and the procedure codes used on a service agreement or a claim.
The service agreement has a total dollar amount on the line item to show the total cost of all CDCS services. You enter the financial management services (FMS) provider number on this line item on the service agreement as well.
Instructions to use inquiry on claims history
Claims inquiry may be helpful when determining the last date of service to end a service agreement and/or close a program. The service agreement will display units and dollar amounts used but does not include information about dates of service.
You can review adjudicated (i.e., processed), paid and denied claims using the claims subsystem. Claims display either in detail or in summary format with several claims per screen. Your security group must include access to the claims subsystem to view claims.
To view claims:
1. Log into the MMIS main menu.
2. Type X next to inquiry under the claims processing application.
3. Press the transmit key to open the claims subsystem key panel screen.
4. Use the four sections on the key panel screen to help narrow the claims selected for inquiry:
Section 1: You must make one selection in section 1. Use the tab key and type X next to the criterion you want to use: all claims, suspended claims, etc.
Section 2: You must make one selection in section 2. Use the tab key and type the search criterion you want to use. If you attempt to enter multiple fields in section 2, you will get the following error message: “Enter only one key format to search (A, B, C or D)”. Typically, an inquiry will be based on a person or a provider for HCBS.
The provider number used in this section can be either the NPI number or the MHCP provider (UMPI) number. If you type the provider number into the wrong field, a message will appear that asks you to correct the highlighted field.
Section 3: Use this section to narrow your search. You can select multiple criteria. For example:
Section 4: Use this section to select a level of detail in the claims to be viewed. The default is S for a summary of the claims that meet the criteria. The other options are D for detail and P for procedure code.
If you use S (summary):
If you use D (detail):
If you use P (procedure code), only claims that include the procedure code you entered in section 3 will be displayed as a summary.
You can also use section 4 to indicate and limit the status of the claims. The most commonly used claims statuses for inquiry are:
5. Press the transmit key to move into the claims data. There are many fields on a claim, including:
Note: Warrant is the payment sent to the provider.
6. Press F3 or F6 to return to the key panel and again to return to the main menu.
7. Log out of MMIS as usual.
Additional resources
DHS – MHCP billing resources
How to Read the PCN, DHS-3948B (PDF)
MHCP Provider Manual – Billing policy overview
MMIS LTSS Manual – CDCS claim payments
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