The recipient has requested continued benefits pending appeal. This service agreement changed to reflect this continuation of benefits until an appeal ruling. If the recipient loses the appeal, the state reserves the right to bill the recipient for the difference between the services received and the level of services appealed. MINN. STAT. SECT 256.045, SUBD. 10.

An order of the commissioner issued regarding an appeal filed by the recipient. This service agreement is based on the order of the commissioner.

Based on an administrative review of the PCA assessment and service plan, or additional information submitted, the department has changed the service agreement.

You requested another copy of the original authorization notice. There are no changes from the original notice.

This service changed due to a rate adjustment. For billing purposes, please make sure you save this copy.

The person has elected to receive the shared service option for PCA or PCA complex services. his allows two or three persons to share PCA services in the same setting at the same time. An agreement with consent is required to grant permission for the agency to place the person’s name in the chart of the other person they share services. The provider agency delivers services according to each individual’s plan of care. The assessment and authorization for shared services based on the person’s 24-hour needs. Participation in a shared care arrangement does not reduce the total number of service units authorized. Minn Stat Sect 256B.0625 and 256B.0659.

This service requires a valid and active ordering NPI.

Changes to this service are due to procedure code changes. Providers: For billing purposes, please make sure you save this copy.

This is a Moving Home Minnesota service.

Service agreement changes were due to procedure code changes. Providers: For billing purposes, please make sure you save this copy. DHS review was required for approval of the EW CLS services.

Starting January 1, 2019, Medical Assistance will directly cover the cost of this personal care assistance and/or home care nursing service agreement instead of the health plan. The health plan will continue to be the payer for other health care services. This service agreement shows the change in payer for personal care assistance services and/or home care nursing services. This service agreement uses current information from the health plan. There are no changes to the amount of services this person is eligible to receive.

Starting July 1, 2018, Medical Assistance will pay an enhanced rate for personal care assistance services and the Consumer Support Grant budget will enhance if you are eligible for 12 or more hours of Personal Care Assistance services per day and have a qualified worker that meets the training requirements. Starting January 1, 2022, the enhanced rate eligibility changed to 10 or more hours of Personal Care services per day. This service agreement shows the change in rate for Personal Care Assistance Complex services. There are no changes to the amount of services this person is eligible to receive. The increase is required for the workers as wages and/or benefits.

Submit claims to DHS for services authorized on this agreement.

Deletion of the units and total amount for this service was necessary because the rate was incorrect.

This service replaces a duplicate service priced with an incorrect rate.

Closing this line item because the provider is no longer active under this provider number beyond the end date.

This service replaces a duplicate closed service because the provider is no longer active.

This is a new line item that authorizes a new service.

Reducing the units or total amount for this service.

The units or total amount for this service was increased.

Reducing the date span on this service. Provide the service for this new time period.

The date span on this service was increased.

The total units/amount and date span was reduced for this service. The person is no longer participating in the program as of the service agreement end date.

The person is no longer participating in the program as of the new service agreement end date. Any approved line item that began after this date is no longer valid.

This denied service agreement entered by mistake or has errors.

NOTE TO PROVIDERS: . . . . Refer to the person’s support plan for details regarding the type, amount, frequency and duration of services to be provided.

Closing this service because the provider changed or incorrect.

This closed service replaces a duplicate service because the provider was changed or incorrect.

Please ignore this letter if it does not show information about your services.

The service closes as of the new service agreement end date.

The units and total amount deleted for this service due to closing the service agreement.

This line item is no longer needed.

Closing this service agreement due to person entering the nursing facility.

Extending the date span and increasing the amount for this service.

Ending the service agreement due to a facility stay that does not allow for the service agreement to remain open.

Extending this service agreement.

This authorization has ended due to person moving to a new county of residence.

You received this letter due to changes to the provider’s records for this service. Contact your case manager or MN Health Care Programs Member helpdesk at 651 431 2670 or 1 800 657 3739 for more information.

Closing this service agreement because more than one PMI number assigned to the person. Do not use the PMI listed on this letter in the future. When you receive the new service agreement letter with the new PMI number, begin using that PMI as of the effective date of the service agreement.

Closing this service agreement because the person enrolled with a managed care program and will begin receiving waiver services through that organization. Services authorized and funded through DHS will end on the closing date and future waiver services authorized and funded through the managed care organization. To continue serving this person contact the enrollee's health plan or health plan's care coordinator.

This Alternative Care service agreement ended due to the person becoming eligible for Medical Assistance.

Use other more appropriate funding instead of the waiver or Alternative Care funds for payment.

Services will be ending effective the end of the waiver span or AC eligibility end date. Person is not continuing on the program.

Providers must continue to be eligible for enrollment in order for authorizations to be valid.

Denying this service due to errors.

CDCS services no longer authorized for this person.