This field is an 11-digit number assigned to the agreement when initially entered into MMIS. This number appears at the top middle of each service agreement screen. The format is YDDDBBBMXXX:

This field records the overall status of the service agreement based on the combination of line-item statuses. The statuses are:

If the service agreement has been routed to DHS for approval or routed to the county/Tribal Nation queue, this field records the three-digit location code and the date it was routed to that location.

This field records the type of home and community-based services (HCBS) program the service agreement supports. Each program has its own agreement type. You enter this code on the AKEY (key panel) screen. The options are:

These fields identify the beginning date and end date of the service agreement. If you leave the end date field blank, MMIS will populate a date 366 days from the begin date here.

This field records the 10-digit national provider identifier (NPI) or unique Minnesota provider identifier (UMPI) number for a provider on certain types of prior authorizations. This field is not used for AC, ECS or waiver service agreement types.

This field is used for chemical health programs. You cannot enter data in this field.

This field records the referring provider number. You use this field for prior authorizations for certain types of Medical Assistance (MA) services. DHS enters the managed care organization (MCO) provider number in this field for service agreements for people on ECS in program type 30 and in managed care.

This field records the total authorized amount. MMIS populates this amount, so you do not need to enter it. It is the sum of all approved, suspended and pended line items entered on the service agreement in ASA3 screens.

This field records the monthly case mix cap from the screening document multiplied by the number of months in the service agreement period (begin and end dates). MMIS populates this field for AC, ECS and EW. The total authorized amount (TOT AUTH AMT) cannot exceed this cap amount. If the service agreement period changes, this amount will change. Leave this field blank for BI, CAC and CADI service agreements.

This field records the total amount of required case management (RCM) that can be authorized for AC and EW with the consumer directed community supports (CDCS) option. It is a protected field. MMIS populates the field when a line item for T2041 is present on ASA3. If the service agreement period changes, this amount will change.

MMIS populates this field with the person’s name from the recipient subsystem based on the RECIP ID entered.

This field records the number assigned to the person, also called the person master index (PMI) number.

MMIS populates this field with the person’s gender based on information from the recipient subsystem.

This field records the person’s date of birth in the format MMDDYYYY. It must match the date in the recipient subsystem. If the birthdate in the recipient subsystem is incorrect, the eligibility worker must change it.

MMIS populates this field with the person’s age, based on their birthdate compared to the AGMT START DT entered on the service agreement.

MMIS populates this field with the person’s living arrangement, based on information from the RLVA screen on the recipient file at the time you enter the service agreement.

MMIS populates this field with the person’s major health care program. MMIS uses information from the RELG screen on the recipient file and compares the AGMT START DT entered on the service agreement to information on the RELG screen. The options are:

These fields record the case manager number and name. Enter the NPI or UMPI provider number of the case manager. MMIS populates the name field. MMIS uses this field to add the case manager name to the recipient and provider service agreement letters.

This field records if the person is eligible for an enhanced rate of payment for their approved personal care assistance (PCA) services. In MMIS, the enhanced rate is called “PCA complex.” It is a mandatory field for all HCBS service agreements.

For more information, refer to:

This field allows you to enter up to four reason codes. These codes are connected to text MMIS will add to all service agreement letters to explain an action or the reason why the letter was produced. Remember to delete the reason code the next time you make changes to the agreement if it no longer applies. Otherwise, MMIS will add the text again to future letters. For the list of codes and related messages, refer to MMIS LTSS Manual – Service agreement reason codes.

This field records whether MMIS should send a letter to the person. It is a required field. If you enter Y, MMIS will send a letter to the person that includes information about:

If you enter N, MMIS will not send a letter. In this case, the lead agency must send an equivalent version.

This is a historical field that is no longer used. For online MMIS users, this field will be blank. In some historical cases, you might see N in this field when the prior authorization request was submitted using Service Agreement, DHS-3070 (PDF).

This field indicates that MMIS will send an authorization letter to each provider with only the provider’s service authorization included. This field defaults to Y and is protected, so you cannot change it.

This field records a three-digit number assigned to a Tribal Nation for some purposes in MMIS. This field is only completed by and mandatory for Tribal Nation staff who enter service agreements. This field allows service agreements to route to a Tribal Nation’s queue when needed. If you do not work for a Tribal Nation, leave this field blank.

These fields are used only with AC service agreements to record information related to fees the person may be responsible to pay. For more information, refer to MMIS LTSS Manual – AC fees and service agreements.

This field transfers suspended or partially suspended service agreements in MMIS from county/Tribal Nation staff to DHS staff, DHS to county/Tribal Nation staff or county/Tribal Nation staff to county/Tribal Nation staff. Enter the applicable routing queue code to transfer a service agreement.

This field also is used when the waiver service agreement overlaps with a home care Type B authorization and MMIS posts exception code 874. For instructions, refer to the text associated with exception code 874 and MMIS LTSS Manual – Service agreement exception codes.

This field records the last date a claim was paid against the service agreement.

This field records if the data was submitted by paper or online. MMIS auto-populates this field as “exam entry” when you submit the service agreement online.

These fields identify if there is text (comments) on these screens. Y indicates yes.

This field records whether the person has a responsible party. This field is mandatory if there is a line item for PCA/CFSS on the ASA3 screen and can be Y or N. If there are no PCA/CFSS line items on the ASA3 screen, leave this field blank.

This field records whether the person will have a fiscal intermediary. This field is mandatory if there is a line item for PCA/CFSS on the ASA3 screen. Enter Y if the service is PCA CHOICE or CFSS using the budget model. If there are no PCA/CFSS line items on the ASA3 screen, leave this field blank.

This field records if the person lives with the responsible party as indicated in RESP PARTY NAME field. This field is mandatory if the RESP PARTY (Y/N) field is Y.

This field records information related to excluded time settings and services. This field is mandatory for BI, CAC and CADI service agreements if T2028 (CDCS) is included on a line item on the ASA3 screen and can be Y or N. This field can be blank if there are no CDCS service line items.

This field allows you to go to a specific line item. It appears above the line items. Type the number of the line item in this field and press the transmit key. To view the last line item, type a high number in this field (e.g., 99). To return to the beginning of the line items, type 01 in this field.

A + (plus) sign above the line items at the right side of the screen indicates there are more line-item screens. MMIS will only display two line items on a screen. Press F7 and F8 to scroll back and forth between line-item screens.

This field is required when a line item has specialized supplies and equipment (E1399 or T2029), MHM tools and equipment for employment (T1999 U6) or MHM supplies and equipment (T2029 U6/NU, U6/RR, or U6/RB). Use this field to enter the name of the item(s). Use the DHS comment screen if you need more room to provide a complete description. For more information, refer to MMIS LTSS Manual – Authorize services that require additional steps.

MMIS populates the name of the service based on the procedure code/modifiers you entered on the line item.

This field records the procedure code associated with each service.

This field records up to four modifiers. Use the tab key to move to each field and attach modifier(s) to a procedure code to identify a different service.

These fields are not used for HCBS program service agreements and are protected, so you cannot enter data.

This field records the referring provider for skilled nursing visits, home health aide and extended home care services. If these types of services are not included on the service agreement, leave this field blank.

These fields record the start and end dates for the service. These dates must fall within the header start and end date on the ASA1 screen.

Note: If you do not enter dates on a line item, MMIS will use the header dates to populate these fields.

This field records the requested rate (dollar/cents amount) per unit of a service. When using this field, the REQ TOT UNITS field must also have a value. This field is not required for services that are manually priced using a lump sum amount in MMIS.

This field records the total units requested for the line item. You must enter a number here to indicate the total units requested when you use the REQ RATE/UNIT field, including for services to be manually priced if using the REQ RATE/UNIT field.

This field records one of the following:

This field records the NPI or UMPI number of the provider who will deliver the service.

MMIS populates this field with the provider’s name, based on information from the provider subsystem using the NPI or UMPI you entered.

This field records that the PCA worker or home care nurse will provide services to more than one person at the same time in the same setting. The valid values are Y or blank.

This field will place text on the service agreement letter for line items with T1019. It is a mandatory field for line items using procedure code T1019. Valid values are:

These fields identify the approved rate/unit and the source. These fields are either populated by MMIS or manually entered, depending on the service and allowable rates.

These two fields change as claims are paid against the line:

This field records the status of the line item. Each line item begins with a default status of S (suspend) until it is changed. Statuses are:

MMIS populates this field with the effective date of the status, based on the last date the status code was entered or changed.

These fields allow you to add up to four reason codes for each line. Press the tab key to move to each field. Each reason code has a message associated with it. When you add a reason code on the line item, the message will appear on the service agreement letter to the provider on that line item. Reason codes are optional. For the list of reason codes and related messages, refer to MMIS LTSS Manual – Service agreement reason codes.

These fields are for chemical health service agreements and are protected for all other types, so you cannot enter data.