Minn. Stat. §256B.0652, subd. 14, Minn. Stat. §256B.85, subd. 8a

DHS is in the process of replacing PCA with CFSS. For more information about this transition, refer to CFSS Manual – Transition from PCA and CSG to CFSS.

Similarities

The lead agency must authorize PCA/CFSS services before services take place (i.e., prior authorization), unless circumstances meet one of the exceptions described on this page.

Differences

There are no differences in this policy for PCA and CFSS.

A provider can request an exception for prior authorization in the following circumstances.

Temporary start of services

The person needed to start services immediately. In this situation, the PCA/CFSS provider agency must request authorization within five days of providing the initial services. For more information, refer to CFSS Manual – 45-day temporary start of PCA/CFSS services.

Medical Assistance (MA) eligibility lapse

The person’s MA eligibility lapsed, and the county/tribal nation retroactively reinstated their eligibility. In this situation, the lead agency (county, tribal nation or managed care organization [MCO]) must enter the PCA/CFSS service authorization based on the date of the current assessment, eligibility and request for authorization. For more information, refer to CFSS Manual – Assessment for PCA/CFSS services.

Denial or adjustment of payment

A third-party payer (e.g., insurance provider) denies or adjusts a payment. In this situation, the provider must submit PCA Technical Change Request, DHS 4074A or CFSS Technical Change Request, DHS 6893K to DHS for an authorization within 20 working days of the notice of denial or adjustment and include a copy of the denial/adjustment notice with their request.

MCO disenrollment

The person temporarily disenrolls from their MCO. For more information, refer to CFSS Manual – PCA/CFSS MCO disenrollment process.

DHS or lead agency error

DHS determines DHS or the lead agency made an error (e.g., the lead agency did not receive a form the provider has a record of sending, DHS or the lead agency gave the provider the wrong information).

All providers must:

The lead agency must:

DHS will process exception requests to determine if they meet exception criteria and responds accordingly.