Void (“Take-Back”) Waiver and Alternative Care (AC) Service Claims for Fee-for-Service

Revised: 01-27-2015

Effective January 1, 2011:

Providers must:

1. Submit their own void (take-back) claims electronically for wavier and AC claims. Refer to the MN–ITS User Guide for Voiding a Claim using MN–ITS.

2. Submit a partial void of a claim by replacing the claim previously paid incorrectly. Refer to the MN–ITS User Guide for Replacing a Claim using MN–ITS.

Lead agencies must follow the steps below when requesting voids for the purpose of adjusting a service authorization/agreement:

1. Contact the provider and request them to do their own void.

2. After waiting 7 days, if the claims are not voided, you may request, on behalf of the provider, that the claims be voided:

a. Complete the Credit Claim Void (take-back) Request (DHS-6207) form and submit it to MHCP by fax at 651-431-7616; or

b. Send an email with the Credit Claim Void (take-back) Request form attached to dhs.void@state.mn.us, enter “Attn: SA Claim Void” in the subject line.

3. After the claim is voided, check the service agreement to make sure the line item’s paid units and/or dollar amounts were adjusted before making changes to the line item (if changes are needed).

Note: Any voids for Managed Care Organizations (MCOs) refer back to the Health Plan.

MHCP will:

1. Void county-initiated claims in the order received.

2. Not process incomplete claim void requests.

3. Report claim void transactions in the Reversal section of the provider’s remittance advice (RA).

Additional Resources

MN–ITS
MHCP X12/NCPDP Submitters
MHCP Provider Manual Billing Policy; MN–ITS and Electronic Billing

If you have questions about this information, call the MHCP Provider Resource Center at 651-431-2700 or 1-800-366-5411.

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