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Type B Home Care Service Agreement MMIS Reason codes

Enter one or more of the following reason codes on entry of home care service agreements when applicable. Please note the specific codes when PCA/CSG assessments result in a change of services. This includes denial, reduction or termination of services.

Text associated with the reason code appears on the SA letter. Reason codes further describe an action taken or changes to services. Reason codes trigger addition of text for legal notification of reduction, termination or denial of PCA services.

Recipient request for reassessment results in no change in need
Personal care assistance (denial, reduction, termination)
Consumer Support Grant (denial, reduction, termination)
Retired reason codes
Denial reason codes for DHS use
Miscellaneous reason codes for DHS use

Recipient request for reassessment results in no change in need

476: YOUR REQUEST HAS BEEN DENIED AS IT REPRESENTS A DUPLICATION OF SERVICES.

Personal care assistance

Use one or more of the following reason codes on PCA service agreements when PCA assessment results in termination, reduction or denial of PCA services.

PCA notice of denial

567 (Updated text 02/04/2011): YOU DO NOT MEET THE ACCESS CRITERIA FOR PCA SERVICES REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

571: BASED ON THE PCA ASSESSMENT CRITERIA EFFECTIVE 7/1/2011, YOU DO NOT MEET THE ACCESS CRITERIA FOR PCA SERVICES BECAUSE YOU ARE NOT DEPENDENT IN TWO OR MORE ACTIVITIES OF DAILY LIVING. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

PCA notice of reduction

542 (MMIS enters reason code 542 automatically on T1019 U5 line): THIS IS A 10-DAY NOTICE THAT THE RECIPIENT'S PERSONAL CARE ASSISTANCE (PCA) SERVICES ARE BEING REDUCED DUE TO NEW ASSESSMENT INFORMATION RECEIVED BY DHS. MINN. STAT. SECT. 256J.31, SUBD. 5.

PCA notice of termination

543: THIS IS A 10-DAY NOTICE THAT THE RECIPIENT'S PERSONAL CARE ASSISTANCE (PCA) SERVICES ARE BEING TERMINATED. DHS RECEIVED NEW ASSESSMENT INFORMATION DETERMINING THAT THE RECIPIENT DOESNOT QUALIFY FOR PCA SERVICES MINN. STAT. SECT. 256J.31, SUBD. 5.

Consumer Support Grant

Use one or more of the following reason codes on CSG service agreements when PCA assessment results in termination, reduction or denial of PCA services.

CSG denial

568 (Updated 02/04/2011): YOU DO NOT MEET THE PCA LEVEL OF CARE ACCESS CRITERIA FOR THE CONSUMER SUPPORT GRANT PROGRAM. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

572: BASED ON THE PCA ASSESSMENT CRITERIA EFFECTIVE 7/1/2011, YOU DO NOT MEET THE PCA LEVEL OF CARE ACCESS CRITERIA FOR THE CONSUMER SUPPORT GRANT PROGRAM. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

CSG notice of reduction

557: THIS IS A 10 DAY NOTICE FOR A REDUCTION OF CONSUMER SUPPORT GRANT PROGRAM MONTHLY BUDGET AMOUNT. BASED ON THE NEW PCA ASSESSMENT CRITERIA EFFECTIVE 1/1/2010, YOU NO LONGER QUALIFY FOR YOUR CURRENT LEVEL OF SERVICES. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0652, SUBD. 6.

CSG notice of termination

570: THIS IS A 10 DAY NOTICE OF TERMINATION FOR CONSUMER SUPPORT GRANT (PROGRAM. BASED ON THE PCA ASSESSMENT CRITERIA EFFECTIVE 7/1/2011, YOU DO NOT HAVE TWO OR MORE DEPENDENCIES IN ACTIVITIES OF DAILY LIVING TO MEET THE CRITERIA FOR PCA SERVICES. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

Retired reason codes

554 (Retired effective 06/30/2011): THIS IS A 30 DAY NOTICE FOR THE TERMINATION OF PCA SERVICES. BASED ON THE NEW PCA ASSESSMENT CRITERIA EFFECTIVE 1/1/2010, YOU NO LONGER MEET THE CRITERIA FOR SERVICES. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

556 (Retired effective 06/30/2011): THIS IS A 30 DAY NOTICE FOR THE TERMINATION OF CONSUMER SUPPORT GRANT PROGRAM. BASED ON THE NEW PCA ASSESSMENT CRITERIA EFFECTIVE 1/1/2010, YOU NO LONGER MEET THE CRITERIA FOR PCA SERVICES. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

Denial reason codes for DHS use

DHS reviewer enters reason codes related to actions taken when denying a service agreement. Generally, lead agency staff does not enter the reason codes below on a service agreement.

405: THIS PRIOR AUTHORIZATION IS EFFECTIVE THE DATE THE REQUEST WAS RECEIVED BY THE DEPARTMENT OF HUMAN SERVICES. MINN. STAT. SECT. 256B.0652

433: THE DEPARTMENT IS UNABLE TO AUTHORIZE HOME CARE SERVICES DUE TO A LAPSE IN THE RECIPIENT'S ELIGIBILITY STATUS. SHOULD THE STATUS OF ELIGIBILITY CHANGE WITHIN 20 WORKING DAYS, A REQUEST MUST BE RESUBMITTED.

437: THERE ALREADY IS A SERVICE AGREEMENT FOR THIS RECIPIENT. THE SERVICE AGREEMENT IS TO A DIFFERENT HOME CARE PROVIDER. THE RECIPIENT MUST TELL THE OTHER PROVIDER OR THE DEPARTMENT THAT THEY NO LONGER WANT TO HAVE SERVICES FROM THE OTHER PROVIDER. THE RECIPIENT SHOULD DO THIS IN WRITING AND GIVE THE LAST DATE OF SERVICE. MINN. STAT. SECT. 256B.0652

461: THE RECIPIENT INDICATED IS A CAC, CADI, TBI OR EW RECIPIENT. AUTHORIZATION FOR SERVICES MUST BE OBTAINED FROM THE COUNTY CASE MANAGER.

465: THIS SERVICE AGREEMENT IS DENIED. FOR EMERGENCIES, RETROACTIVE TEMPORARY 45 DAY AUTHORIZATIONS MUST BE REQUESTED WITHIN FIVE (5) WORKING DAYS AFTER GIVING THE INITIAL SERVICE. MINN. STAT. SECT. 256B.0652, SUBD. 9 and 14

474: THE PROVIDER HAS FAILED TO RESPOND TO A REQUEST FOR FURTHER INFORMATION. THIS SERVICE AGREEMENT HAS BEEN DENIED. THE PROVIDER WILL HAVE TO SUBMIT A NEW SERVICE AGREEMENT, A MEDICAL ASSISTANCE PRIVATE DUTY NURSING ASSESSMENT (DHS-4071A) AND THE PLAN OF CARE, WITH ALL NECESSARY DOCUMENTATION FOR SERVICES REQUESTED.

476: YOUR REQUEST HAS BEEN DENIED AS IT REPRESENTS A DUPLICATION OF SERVICES.

479: THE CLIENT INDICATED IS A WAIVER RECIPIENT. AUTHORIZATION FOR THIS PROGRAM IS INITIATED THROUGH THE COUNTY CASE MANAGER USING A WAIVER SERVICE AGREEMENT. THE PROVIDER SHOULD CONTACT THE RECIPIENT'S COUNTY CASE MANAGER FOR REQUEST OF HOME CARE SERVICES.

480: THIS RECIPIENT IS ENROLLED IN A PREPAID MEDICAL ASSISTANCE PLAN AND THE HEALTH PLAN IS RESPONSIBLE FOR MEETING THE RECIPIENT'S HOME CARE NEEDS.

481: THE RECIPIENT IS CURRENTLY RESIDING IN A HOSPITAL, LONG TERM CARE FACILITY, IMD, RULE 36 FACILITY OR NON-NEGOTIATED RATE FACILITY. IF THIS LIVING CONDITION CHANGED, THEN RESUBMIT REQUEST FOR SERVICES. MINN. STAT. SECT. 256B.0625, SUBD. 19A.

482: THIS SERVICE AGREEMENT IS REJECTED AS IT IS A DUPLICATE SERVICE AGREEMENT REQUEST.

483: THE PROVIDER IS NOT AUTHORIZED TO USE THE PROCEDURE CODE REQUESTED.

491: PER FEDERAL REGULATIONS, THE REQUESTED SERVICES ARE DENIED EFFECTIVE THE DATE THE RECIPIENT ELECTED THE HOSPICE BENEFIT. THESE SERVICES ARE INCLUDED IN THE HOSPICE BENEFIT AND THEREFORE THE RESPONSIBILITY OF THE HOSPICE PROVIDER. IT HAS BEEN DETERMINED THAT THESE SERVICES DUPLICATE THE COVERED HOSPICE BENEFIT FOR THE TERMINAL ILLNESS OR RELATED CONDITION. 42 C.F.R. 418 MINN. STAT. SECT. 256B.042, 0625, 0651, 0913 AND 0915. MINN. R. 9505.0290, 9505.0295, 9505.0297.

495: THE DEPARTMENT IS UNABLE TO AUTHORIZE THE PCA SERVICE REQUESTED BASED ON THE RECIPIENT'S INELIGIBLE LIVING ARRANGEMENT. THE PROVIDER ORGANIZATION OR THE RESPONSIBLE PARTY MAY CONTACT THE COUNTY OF FINANCIAL RESPONSIBILITY TO INQUIRE ABOUT THE RECIPIENT'S LIVING ARRANGEMENT CODE. THE PROVIDER DOES NOT NEED TO CONTACT THE PUBLIC HEALTH NURSE. SHOULD THE COUNTY MAKE AN ADJUSTMENT IN THE RECIPIENT'S LIVING ARRANGEMENT, THE PUBLIC HEALTH NURSE MAY RESUBMIT A SERVICE AGREEMENT FOR PCA SERVICES. MINN. STAT. SECT. 256B.0625, SUBD.19A

500: YOUR REQUEST IS DENIED. THE RECIPIENT ID OR DATE OF BIRTH IS EITHER MISSING OR INVALID. PLEASE CHECK YOUR RECORDS. YOU MAY HAVE OMITTED OR WRITTEN DOWN THE WRONG ID NUMBER. CHECK THE EVS SYSTEM FOR VERIFICATION AND RESUBMIT YOUR REQUEST WITH THE CORRECT RECIPIENT INFORMATION. MINN. STAT. SECT. 256B.0651

509: PCASERVICES MUST BE REQUESTED BY THE PUBLIC HEALTH NURSE OF THE RECIPIENT’S COUNTY OF RESIDENCE. MINN. STAT. SECT. 256B.0659

512: THE DEPARTMENT HAS DENIED YOUR REQUEST AS IT CAN ONLY APPROVE SERVICES FOR UP TO 45 DAYS. FOR FURTHER AUTHORIZATION OF SERVICES, YOU MUST FOLLOW DEPARTMENT PROCEDURES AND SUBMIT REQUIRED DOCUMENTATION TO THE DEPARTMENT. MINN. STAT. SECT. 256B.0652

513: THE DEPARTMENT HAS DENIED YOUR REQUEST BECAUSE THE PROVIDER ID NUMBER IS EITHER MISSING OR THE NUMBER INDICATED ON THIS REQUEST IS NOT A VALID MINNESOTA HEALTH CARE PROGRAM OR NATIONAL PROVIDER ID. PLEASE CHECK YOUR RECORDS. YOU MAY HAVE OMITTED OR WRITTEN DOWN THE WRONG NUMBER. MINN. STAT. SECT. 256.0651

514: THIS REQUEST FOR SERVICE AGREEMENT WAS DENIED BECAUSE THE PRIMARY ICD-9-CM CODE IS EITHER MISSING, INVALID OR NOT SPECIFIC. PLEASE REFER TO THE ICD-9-CM MANUAL FOR THE CORRECT CODE. FOR RECONSIDERATION, SUBMIT THE REJECTED SERVICE AGREEMENT WITH THE CORRECTED ICD-9-CM CODES TO THE DEPARTMENT BY MAIL OR BY FAX TO (651) 431-7432 WITHIN 10 WORKING DAYS.

516: THE HOME CARE SERVICE AGREEMENT THAT WAS SUBMITTED HAS BEEN DENIED AS IT WAS IMPROPERLY OR INCOMPLETELY FILLED IN AND/OR CONTAINS INSUFFICIENT INFORMATION. PLEASE CHECK YOUR RECORDS AND RESUBMIT WITH COMPLETE INFORMATION. MINN. STAT. SECT. 256B.0652

517: THIS SERVICE AUTHORIZATION IS DENIED BECAUSE IT HAS BEEN MORE THAN 30 DAYS AND YOU HAVE NOT CHOSEN A PROVIDER FOR PCASERVICES. WHEN YOU CHOOSE A PROVIDER, CONTACT THE PUBLIC HEALTH NURSE AT YOUR COUNTY WITH YOUR CHOICE. MINN. STAT. SECT. 256B.0651

518: AUTHORIZATION OF HOME CARE IS REQUIRED BEFORE PROVIDING SERVICES. FOR EXCEPTION ON RETROACTIVE AUTHORIZATIONS REFER TO MINNESOTA HEALTH CARE PROGRAMS PROVIDER MANUAL CHAPTER 24. MINN. STAT. SECT 256B.0652

519: THE DEPARTMENT HAS RECEIVED A PLAN OF CARE WITHOUT A CORRESPONDING SERVICE AGREEMENT. THEREFORE A SERVICE AGREEMENT COULD NOT BE APPROVED. TO REQUEST A SERVICE AUTHORIZATION, YOU MUST SUBMIT THE PLAN OF CARE AND SERVICE AGREEMENT. MINN. STAT. SECT. 256B.0651

520: THIS REQUEST FOR SERVICE AGREEMENT WAS DENIED BECAUSE THE SECOND ICD-9-CM CODE IS EITHER MISSING, INVALID OR NOT SPECIFIC. SUBMIT THE REJECTED SERVICE AGREEMENT WITH THE CORRECTED ICD-9-CM CODES TO THE DEPARTMENT BY MAIL OR BY FAX TO (651) 431-7432 WITHIN 10 WORKING DAYS.

521: THIS REQUEST FOR SERVICE AGREEMENT WAS DENIED BECAUSE THE THIRD ICD-9-CM CODE IS EITHER MISSING, INVALID OR NOT SPECIFIC. FOR RECONSIDERATION, SUBMIT THE REJECTED SERVICE AGREEMENT WITH THE CORRECTED ICD-9-CM CODES TO THE DEPARTMENT BY MAIL OR BY FAX TO (651) 431-7432 WITHIN 10 WORKING DAYS.

527: THE DEPARTMENT IS UNABLE TO AUTHORIZE HOME CARE SERVICES. THE RECIPIENT’S MAJOR PROGRAM DOES NOT COVER THE REQUESTED SERVICE.

533: THE RECIPIENT HAS CHOSEN TO RECEIVE HOME AND COMMUNITY BASED SERVICES THROUGH THE CONSUMER SUPPORT GRANT. THEREFORE, WE HAVE ENDED OR DENIED THIS AUTHORIZATION FOR HOME CARE SERVICES.

Miscellaneous reason codes for DHS use

DHS reviewer enters reason codes related to actions taken on a service agreement. Generally, lead agency staff does not enter the reason codes below on a service agreement.

400: THIS WAS SUBMITTED ON THE WRONG FORM. IF YOU HAVE QUESTIONS, PLEASE CONTACT THE DHS PROVIDER HELP DESK AT 1 (800) 366-5411, (651) 431-2700 OR ON THEIR WEBSITE AT WWW.DHS.STATE.MN.US/PROVIDER.

406: THE RECIPIENT HAS REQUESTED THESE SERVICES FROM A NEW PROVIDER. WE HAVE ENDED THIS SERVICE AGREEMENT ON THE DATE SHOWN ABOVE.

407: DUE TO ADDITIONAL INFORMATION RECEIVED ON THIS RECIPIENT, THIS SERVICE AGREEMENT HAS BEEN REVISED.

410: THIS IS A TEMPORARY 45 DAY INCREASE TO THE SERVICE AGREEMENT BECAUSE THE RECIPIENT'S NEEDS HAVE TEMPORARILY CHANGED. IF SERVICES NEED TO CONTINUE AT THIS LEVEL, YOU MUST FOLLOW DEPARTMENT PROCEDURES AND SUBMIT REQUIRED DOCUMENTATION. IF NO FURTHER INFORMATION IS RECEIVED, THE SERVICE AGREEMENT WILL REVERT BACK TO THE PREVIOUS AUTHORIZATION. MINN. STAT. SECT. 256B.0652

416: THE RECIPIENT HAS REQUESTED CONTINUED BENEFITS PENDING APPEAL. THIS SERVICE AGREEMENT HAS BEEN AMENDED TO REFLECT THIS CONTINUATION OF BENEFITS UNTIL AN APPEAL RULING IS MADE. 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

422: THE RECIPIENT HAS CHOSEN TO RECEIVE HOME AND COMMUNITY-BASED WAIVER SERVICES. WE HAVE ENDED THIS SERVICE AGREEMENT FOR HOME CARE SERVICES. ALL HOME CARE SERVICES MUST BE PRIOR AUTHORIZED BY THE RECIPIENT'S CASE MANAGER. MINN. STAT. SECT. 256B.49, AND MINN. STAT. SECT. 256B.095

425: AN ORDER OF THE COMMISSIONER HAS BEEN ISSUED REGARDING AN APPEAL FILED BY THE RECIPIENT. THIS SERVICE AGREEMENT IS BASED ON THE ORDER OF THE COMMISSIONER.

427: BASED ON AN ADMINISTRATIVE REVIEW OF THE ASSESSMENT AND CARE PLAN, THE DEPARTMENT HAS CHANGED THE SERVICE AGREEMENT. MINN. STAT. SECT. 256B.0652

428: THERE WAS AN ERROR IN THE FIRST SERVICE AGREEMENT YOU RECEIVED. THIS IS A CORRECTED SERVICE AGREEMENT.

430: THIS SERVICE AGREEMENT HAS BEEN CANCELLED BECAUSE THE RECIPIENT HAS ENTERED A MEDICAL FACILITY OR AN INSTITUTION. IF THE RECIPIENT LEAVES THE FACILITY WITHIN THE LENGTH OF THE ASSESSMENT PERIOD, PLEASE CONTACT THE COUNTY PUBLIC HEALTH NURSE TO REQUEST A REOPENING OF THE SERVICE AGREEMENT. MINN. STAT. SECT. 256B.0625.

436: THIS SERVICE AGREEMENT IS PENDED. THE PROVIDER MUST SUBMIT THE PCA ASSESSMENT AND SERVICE PLAN (DHS_3244) WITHIN 20 WORKING DAYS. MINN. STAT. SECT. 256B.0651

445: IN ORDER FOR THE DEPARTMENT TO DETERMINE THAT THE RECIPIENT MEETS THE CRITERIA FOR LEVEL I BEHAVIOR, THE PROVIDER MUST SUBMIT SUPPORTING DOCUMENTATION SUCH AS CURRENT MENTAL HEALTH SCREENING THE PROVIDER MUST SUBMIT THE INFORMATION REQUESTED WITHIN 20 WORKING DAYS TO THE COUNTY PUBLIC HEALTH NURSE. A DETERMINATION WILL BE MADE BASED ON THE INFORMATION WE HAVE.

446: THE REQUEST FOR HOME CARE SERVICES HAS BEEN REFERRED TO THE REGIONAL TREATMENT CENTER PREADMISSION SCREENING TEAM. DHS IS AWAITING RESULTS OF THE TEAM'S EVALUATION FOR HOME CARE SERVICES AT THE AMOUNT OR LEVEL REQUESTED. AFTER THE REVIEW THE DEPARTMENT MAY OR MAY NOT BE ABLE TO AUTHORIZE THE CONTINUATION OF THESE SERVICES OR THE SERVICES AUTHORIZED MAY BE DIFFERENT IN AMOUNT OR TYPE FROM THIS AUTHORIZATION. AT THIS TIME NO ACTION IS REQUIRED ON THE PART OF THE PROVIDER.

448: THE SERVICE AGREEMENT IS CANCELED AS REQUESTED BY THE PROVIDER.

449: DHS HAS APPROVED TEMPORARY HOME CARE SERVICES. TEMPORARY SERVICES CAN BE APPROVED FOR UP TO 45 DAYS. IF YOU WANT SERVICES TO CONTINUE, YOUR PROVIDER MUST SEND IN A NEW REQUEST. DHS WILL REVIEW THE NEW REQUEST. YOUR NEW SERVICES MAY BE DIFFERENT IN AMOUNT OR TYPE FROM THESE TEMPORARY SERVICES. IF YOU HAVE PCA SERVICES, YOU NEED TO ASK THE COUNTY FOR A PCA ASSESSMENT.

MINN. STAT. SECT. 256B.0652 SUBD. 9

455: TIME AUTHORIZED FOR BEHAVIOR WAS LESS THAN REQUESTED ON THE ASSESSMENT. THE TOTAL TIME INDICATED ON THE ASSESSMENT HAS NOT BEEN SUPPORTED THROUGH DOCUMENTATION TO BE MEDICALLY NECESSARY.

480: THIS RECIPIENT IS ENROLLED IN A PREPAID MEDICAL ASSISTANCE PLAN. THE PLAN IS RESPONSIBLE FOR MEETING THE RECIPIENT'S HOME CARE NEEDS.

482: THIS SERVICE AGREEMENT IS REJECTED AS IT IS A DUPLICATE SERVICE AGREEMENT REQUEST.

483: THE PROVIDER IS NOT AUTHORIZED TO USE THE PROCEDURE CODE REQUESTED.

488: YOU REQUESTED ANOTHER COPY OF THE ORIGINAL AUTHORIZATION NOTICE. NO CHANGES WERE MADE FROM THE ORIGINAL NOTICE.

497: THIS SERVICE AGREEMENT IS PENDED BECAUSE YOU HAVE NOT CHOSEN A PROVIDER FOR PCASERVICES. YOU HAVE 30 DAYS TO CONTACT THE PUBLIC HEALTH NURSE AT YOUR COUNTY WITH THE PROVIDER OF YOUR CHOICE.

502: THE DEPARTMENT HAS ADJUSTED THE END DATE OF THIS SERVICE AGREEMENT DUE TO A CHANGE IN THE RECIPIENT'S HOME CARE SERVICES. A NEW SERVICE AGREEMENT WILL BE ISSUED FOR THE REMAINING DATES ORIGINALLY AUTHORIZED ON THIS SERVICE AGREEMENT.

506: THIS SERVICE AGREEMENT HAS BEEN ENDED DUE TO A NEW ASSESSMENT DONE BY THE PUBLIC HEALTH NURSE OR A REVIEW BY A DHS. ANOTHER SERVICE AGREEMENT WILL BE ISSUED.

510: THE REQUESTED SERVICES DO NOT REQUIRE A SERVICE AGREEMENT OR YOU ARE REQUESTING SERVICES WHICH HOME CARE DOES NOT AUTHORIZE. MINN. STAT. SECT. 256B.0652

522: DUE TO MISSING OR INCORRECT INFORMATION THE DEPARTMENT IS UNABLE TO PROCESS THIS SERVICE AGREEMENT CORRECTION REQUEST. PLEASE SUBMIT TO THE DEPARTMENT BY MAIL OR BY FAX TO (651) 431-7432 A COPY OF THE CURRENT PLAN OF TREATMENT OR PCA ASSESSMENT AND SERVICE PLAN (DHS-3244). MINN. STAT. SECT. 256B.0625 AND 256B.0651

528: YOU ARE REQUESTING AN INCREASE IN SERVICES FOR MORE THAN 45 DAYS. THE HOME CARE FAX FORM WITH AN UPDATED PLAN OF CARE IS REQUIRED. A SERVICE AGREEMENT SHOULD NOT BE USED TO REQUEST AN INCREASE.

530: THIS RECIPIENT HAS CHOSEN THE FLEXIBLE USE OPTION. THE REMAINDER OF THIS SERVICE AUTHORIZATION HAS BEEN ADJUSTED TO REFLECT PREVIOUS UTILIZATION.

531: TELEPHONE ASSESSMENTS, FACE-TO-FACE ASSESSMENTS AND SERVICE UPDATES MUST BE REQUESTED FOR A ONE DAY PERIOD OF TIME. THE BEGIN DATE AND END DATE MUST BE THE SAME AND MUST INDICATE THE DATE YOU ACTUALLY PERFORMED THE ASSESSMENT.

532: THE RECIPIENT HAS ELECTED TO RECEIVE THE SHARED SERVICE OPTION FOR PRIVATE DUTY NURSING (PDN) SERVICES. THIS ALLOWS TWO RECIPIENTS TO SHARE PDN SERVICES IN THE SAME SETTING AT THE SAME TIME FROM THE SAME PDN. AN AGREEMENT WITH CONSENT IS REQUIRED TO GRANT PERMISSION FOR THE AGENCY TO PLACE THE RECIPIENT'S NAME IN THE CHART OF THE OTHER RECIPIENT THEY ARE SHARING SERVICES WITH. THE PROVIDER AGENCY DELIVERS SERVICES ACCORDING TO EACH RECIPIENT'S PLAN OF CARE AND INDIVIDUAL NEEDS. THE ASSESSMENT AND AUTHORIZATION FOR SHARED PDN SERVICES ARE BASED ON THE RECIPIENT'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

535: THIS SERVICE AGREEMENT IS NEAR OR AT THE MAXIMUM AMOUNT OF SERVICES ALLOWED BASED ON THE ASSESSED NEEDS OF THE RECIPIENT. IF THERE IS A NEED FOR ADDITIONAL SERVICES DURING THIS AUTHORIZATION PERIOD, YOU MUST CONTACT THE PUBLIC HEALTH NURSE TO COORDINATE THE USE OF AVAILABLE SERVICE AGREEMENT AMOUNTS.

537: THIS SERVICE AGREEMENT IS DENIED DUE TO USE OF INCORRECT FORM. PLEASE RESUBMIT YOUR REQUEST ON THE HOME CARE - PDN ASSESSMENT FORM (DHS-4071A). MINN. STAT. SECT. 256B.0625 AND 265B.0652

540: UNITS MAY BE USED WITHIN THE SERVICE DATES OF THE LINE THEY ARE AUTHORIZED ON. UNUSED UNITS WILL NOT BE TRANSFERRED TO OTHER LINES.

541: YOU HAVE FAILED TO PROVIDE SUFFICIENT DOCUMENTATION TO SUPPORT YOUR AUTHORIZATION REQUEST. PLEASE SUBMIT A NEW AUTHORIZATION WITH ALL ADDITIONAL PERTINENT INFORMATION.

545: THE RECIPIENT IS IN THE MINNESOTA RESTRICTED RECIPIENT PROGRAM AND THEREFORE RESTRICTED FROM USING PCA CHOICE AND FLEXIBLE USE OF PCA UNITS. THE RESTRICTIONS CONTINUE UNTIL PCA SERVICES ARE NO LONGER NEEDED OR THE RECIPIENT IS NO LONGER IN THE MINNESOTA RESTRICTED RECIPIENT PROGRAM. 42 C.F.R. 431.54 (E), MINN. STAT. SECT. 256.045. Minn. R. 9505.2165, SUBP. 10B. .

546: THIS IS A SHORT-TERM PCA AUTHORIZATION BECAUSE THE RECIPIENT MUST CHOOSE A PERSONAL CARE PROVIDER ORGANIZATION OR A MEDICARE-CERTIFIED AGENCY WITHIN 30 DAYS. THE RECIPIENT IS IN THE MINNESOTA RESTRICTED RECIPIENT PROGRAM AND IS RESTRICTED FROM USING PCA CHOICE AND FLEXIBLE USE. CURRENT PROVIDER MUST HELP TRANSITION THE RECIPIENT TO A NON-PCA CHOICE AGENCY. CONTACT 1 (866) 333-2466 OR DHS.Disability-linkage@state.mn.us FOR PCA PROVIDER LISTS. 42 C.F.R. 431.54 (E), MINN. STAT. SECT. 256B.0659, MINN. R. 9505.2165..

547: THIS PCA SERVICE AUTHORIZATION IS ON HOLD BECAUSE THE RECIPIENT MUST CHOOSE A PERSONAL CARE PROVIDER ORGANIZATION (PCPO) OR MEDICARE-CERTIFIED HOME HEALTH AGENCY. IF A PCPO OR MEDICARE CERTIFIED AGENCY IS NOT CHOSEN WITHIN 30 DAYS, DHS WILL DENY THIS AUTHORIZATION AND UNITS WILL BE LOST. RECIPIENTS MAY CONTACT DHS.DISABILITY-LINKAGE@STATE.MN.US OR CALL 1 (866) 333-2466 FOR A LIST OF NON-PCA CHOICE PROVIDERS. 42 C.F.R. 431.54, MINN. STAT. SECT. 256B.0659; MINN. R. 9505.2165.

548: THIS PCA SERVICE AUTHORIZATION IS DENIED BECAUSE THE RECIPIENT DID NOT CHOOSE A PERSONAL CARE PROVIDER ORGANIZATION OR A MEDICARE-CERTIFIED HOME HEALTH AGENCY AS REQUIRED BY THE MINNESOTA RESTRICTED RECIPIENT PROGRAM. PCA SERVICES CANNOT BE AUTHORIZED UNTIL THE DATE DHS RECEIVES A HOME CARE FAX FORM (DHS-4074) FROM A NEW NON-PCA CHOICE AGENCY DOCUMENTING A CHANGE IN PROVIDERS. 42 C.F.R. 431.54(E), MINN. STAT. SECT. 256B.0659; MINN. R. 9505.2165..

550: REQUESTS FOR AUTHORIZATION RELATED TO PMAP LAPSE MUST BE SUBMITTED WITHIN 30 DAYS OF PMAP DISENROLLMENT - SEE TEMPORARY HEALTH PLAN DISENROLLMENT PROCESS LOCATED IN THE PCA PORTAL PAGES.

551: REQUESTS FOR AUTHORIZATION RELATED TO PMAP LAPSE ARE LIMITED TO THE THREE MONTH TIME PERIOD IMMEDIATELY FOLLOWING PMAP DISENROLLMENT - SEE TEMPORARY HEALTH PLAN DISENROLLMENT PROCESS LOCATED IN THE PCA PORTAL PAGES.

552: REQUESTS FOR AUTHORIZATION RELATED TO PMAP LAPSE MUST INCLUDE A CURRENT COPY OF THE PMAP AUTHORIZATION - SEE TEMPORARY HEALTH PLAN DISENROLLMENT PROCESS LOCATED IN THE PCA PORTAL PAGES.

553: THE TIME SPAN OF YOUR SERVICE AGREEMENT FOR PCA SERVICES HAS DECREASED DUE TO CHANGES IN THE PCA PROGRAM STARTING 7/1/2011. MOST PEOPLE WILL GET REASSESSED USING THE NEW PCA CRITERIA BETWEEN 6/1/11 AND 11/30/11. THE ASSESSOR WILL CONTACT YOU TO SET UP YOUR REASSESSMENT TIME.

555: THIS IS A 30-DAY NOTICE FOR A REDUCTION OF PCA SERVICES. BASED ON THE NEW PCA ASSESSMENT CRITERIA EFFECTIVE 1/1/2010, YOU NO LONGER QUALIFY FOR YOUR CURRENT LEVEL OF SERVICES. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0652, SUBD. 6.

558: THE RECIPIENT HAS CHOSEN TRADITIONAL PCA SERVICES. THE PUBLIC HEALTH NURSE MUST AUTHORIZE A CHANGE TO PCA CHOICE BEFORE DHS CAN PROCESS THIS REQUEST FOR TRANSFER.

559: PCA SERVICES CAN NOT BE AUTHORIZED PRIOR TO THE DATE OF THE PCA ASSESSMENT AND SERVICE PLAN.

560: THE RECIPIENT HAS CHOSEN PCA CHOICE AND IS LIMITED TO ONE FISCAL INTERMEDIARY PROVIDER.

561: THE RELEASE SUBMITTED WITH THIS REQUEST FOR TRANSFER IS NOT SIGNED BY THE RECIPIENT.

562: THE RELEASE SUBMITTED WITH THIS REQUEST FOR TRANSFER IS NOT SIGNED BY THE RESPONSIBLE PARTY.

563: THE START DATE OF THIS TRANSFER IS DELAYED DUE TO PAID CLAIMS FOR THESE SERVICES TO ANOTHER PROVIDER.

564: THE END DATE OF THIS INCREASE REQUEST IS ADJUSTED TO MAINTAIN THE ESTABLISHED CERTIFICATION PERIOD.

565: THE RECIPIENT HAS ELECTED TO RECEIVE THE SHARED SERVICE OPTION FOR PCA SERVICES. THIS ALLOWS TWO OR THREE RECIPIENTS TO SHARE PCA SERVICES IN THE SAME SETTING AT THE TIME. AN AGREEMENT WITH CONSENT IS REQUIRED TO GRANT PERMISSION FOR THE AGENCY TO PLACE THE RECIPIENT'S NAME IN THE CHART OF THE OTHER RECIPIENT THEY SHARE SERVICES WITH. THE PROVIDER AGENCY DELIVERS SERVICES ACCORDING TO EACH INDIVIDUAL'S PLAN OF CARE. THE ASSESSMENT AND AUTHORIZATION FOR SHARED SERVICES IS BASED ON THE RECIPIENT'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 AND256B.0659

566: REQUEST FOR QUALIFIED PROFESSIONAL SUPERVISION UNITS EXCEEDS ANNUAL LIMIT OF 96 UNITS. SUBMIT A REQUEST FOR ADDITIONAL UNITS ON THE HOME CARE FAX FORM (DHS-4074) AND FAX TO (651) 431-7432. MINN.STAT. SECT. 256B.0659

569: THIS IS A 30 DAY NOTICE OF TERMINATION FOR PCA SERVICES. BASED ON THE PCA ASSESSMENT CRITERIA EFFECTIVE 7/1/2011, YOU DO NOT HAVE TWO OR MORE DEPENDENCIES IN ACTIVITIES OF DAILY LIVING TO MEET THE CRITERIA FOR PCA SERVICES. REFER TO YOUR PCA ASSESSMENT FOR MORE DETAILED INFORMATION. MINN. STAT. SECT. 256B.0625, SUBD. 19A

858: YOU RECEIVED THIS LETTER DUE TO CHANGES TO THE PROVIDER'S RECORDS FOR THIS SERVICE. CONTACT YOUR CASE MANAGER