DHS may ask processing entities who do not complete the HPEN ticket form correctly to review these guidelines and send a new HPEN ticket.
Tickets marked as “Urgent” must indicate which enrollee has the urgent medical need and detail why their situation meets one of the following reasons:
Providers reporting the enrollee has no coverage should be directed to contact the MHCP Provider Resource Center for questions about billing, coverage, and eligibility. The MHCP Provider Resource Center will contact the Managed Care Enrollment Team on their behalf with all relevant information if needed.
For non-case specific or generic questions, select the “General Request” option on the HPEN web form.
For requests related to a specific case or enrollee select the “Case Specific” option on the HPEN web form. Case Number, PMI, Enrollee Name, Delivery Date, Health Plan, Request Reason, and Issue Description are required fields.
The Health Plan field should contain the name of the enrollee’s current plan. If they are not on a plan, enter the plan they wish to be enrolled on. For general questions, “N/A” can be used if it is appropriate.
Use the following table to determine the appropriate Request Reason and the information that needs to be included in the Issue Description field.
Request Reason | Situation Description | Information Required in the Issue Description Field |
Adjustments | · Enrollees who are incorrectly enrolled in or disenrolled from a health plan due to system problems· Errors specific to health plan enrollment or capitation payment An adjustment will be denied or delayed if: · Coding is incorrect (counties or tribes will be notified to correct coding if appropriate)· The request is for an unreasonable length of time or is not timely· Not enough information given· The adjustment was not requested within one year after the capitation payment was received or should have been received by the health planGo to incarceration or newborns for specific criteria needed to complete those requests. | Explain the reason for the request and include: · Dates for which the adjustment is being requested (month and year)· Pay or recover capitation from health plan· Name of the health plan DHS must pay capitation to or DHS must recover capitation from.· The health plan ID number if possible· For inpatient stays, the date of admission into the hospital and the date of discharge from the hospital |
Health Plan Enrollment | · A processing entity is unable to add an enrollment span in MMIS · An enrollment error occurs that the processing entity is not able to resolve· Other enrollment issues occur that prevent the processing entity from entering an enrollment span· A provider cannot verify the health plan enrollment. Refer to Pharmacy or Provider Issue for guidance. | · Give the name of the health plan the enrollee is requesting.· Explain the issue and provide relevant details as needed.· Include any edit messages if applicable. |
Exclusions | Instructions vary. Review the Exclusions page in this manual before sending a request. | · Explain issue and provide relevant details.· Provide the exclusion that needs to be added to MMIS.· Only DHS can update AB, CD, DO, JJ, KK, NN, US exclusions. |
Indian Health Services (IHS) Code on RCIP | Indian Health Services Field (IHS) on RCIP in MMIS needs to be updated Other demographic issues need to be reported to HCESS | · Is the race code “N” on RCIP?· Is the value for IHS code 0-4? (See RCIP page in MMIS user manual for codes.)· Does an MM exclusion need to be added? |
IMD Stays | Review the IMD and Residential Treatment Facilities Procedures page in ONEsource. Send an HPEN ticket if: · The enrollee has an IMD span that is preventing them from getting urgent medical careAND · They were enrolled in a health plan during their IMD stay. | · Date entered and left facility.· Name of facility· NPI number for facility· Address of facility· If medical services are being denied |
Incarceration | For METS: As directed by Add Incarceration Evidence or Edit Incarceration Evidence in OneSource. For MAXIS: As directed by Incarceration as a Change in Circumstances in MAXIS in ONEsource. | · Facility name· Facility type: 68 or 69· Known Incarceration start date and release date if known |
Moving Home Minnesota Requests | A product type needs to be changed in MMIS for MSHO and MSC+ members who become eligible or ineligible for the Moving Home Minnesota program. A DHS enrollment coordinator must make these updates. | · Date member moved from institution to community or from the community to an institution. |
Newborns | · A Processing entity is unable to add an enrollment span for a newborn’s birth month due to a system issue or because it has been more than 90 days since birth. | The newborn’s eligibility in MMIS must begin on the first day of the birth month to enroll in a health plan. · Newborn’s name· Newborn’s PMI· Newborn’s date of birth· Mom’s name· Mom’s PMI· If Mom and baby are on different cases, include both case numbers. |
Nursing Facility (NF) Liability | · Use this option to report overlapping P spans on RLVA screen in MMIS that result in an edit that prevents processing agencies from updating MMIS.· NF liability only applies to SNBC and MSHO and determines whether the health plan or the state is responsible for nursing facility payments.· Nursing facilities can contact the health plan with questions. | · Explain issue and provide relevant details. |
Other Health Plan Enrollment Issue | · Use this option if none of the other items on this list describe a worker’s question or problem. · Questions can be general or case specific.· Tickets using this option will help DHS add new items to this page and the HPEN ticket system. | · Explain issue and provide relevant details.· If reporting an MMIS Edit message: · Copy and paste the full text of the edit received.· Explain what actions were being taken when error or edit occurred. |
Overlapping MCRE/MA Spans with Elderly Waiver | · Elderly waivers can be administered through both FFS and a health plan. · In situations where a member is on MCRE and is assessed for MA mid-month, resulting in overlapping MCRE and MA spans, and the member is eligible for an elderly waiver, submit a HPEN ticket to DHS for review. · DHS will work with contract management to determine if the member will have their health plan coverage updated or moved to FFS for the month in which the MCRE and MA spans overlap. | · Include the month in which the member has overlapping MCRE and MA eligibility and has an elderly waiver. |
Pharmacy or Provider Issue | · An enrollee is unable to get medical services or prescriptions filled even though the RPPH screen in MMIS shows they are enrolled in managed care, and they have provided their ID cards.· Processing entities should verify this is not caused by a duplicate PMI or an eligibility issue before sending a ticket.· Enrollees should be advised to contact their health plan to verify member information and that the provider is in-network.· Counties and tribes should not submit an HPEN ticket on behalf of a provider. Advise providers to contact the MHCP Provider Resource Center for questions about billing, coverage, and eligibility. The MHCP Provider Resource Center will contact the Managed Care Enrollment Team on their behalf with all relevant information. | · Pharmacy or provider name· Pharmacy or provider NPI· If the Health Plan was contacted – and if so, what their response was· Date of service· Explanation of the issue and relevant details |
Plan Change – After Cutoff but before Capitation | · An enrollment form is received after the managed care enrollment cut off, but on or before the first capitation day,· And there is a medical need, · And the requested plan is different from the default plan the person has been enrolled in Note: This does not guarantee the change will be made for the next month. | · Date enrollment request was received· Name of the health plan the enrollee is requesting· Reason that the enrollment was not processed timely· Description of the medical need |
Plan Change – Agency Error | · The enrollee must request this change. · Processing entities should work with the enrollee to determine if a change for the next available month is acceptable. · If the enrollee needs to be enrolled in a health plan for a past date, submit an HPEN ticket to request an agency error change option.· For examples, refer to the Agency Error section of Changing Health Plans in this manual. | · Date enrollment request was received· Name of the health plan the enrollee is requesting· Any other relevant details |
Plan Change –AHPS eligibility | · Send an HPEN ticket in the following situations, as directed by the Annual Change Option section of Changing Health Plans page in this manual:· Enrollee lost MA or MCRE eligibility during AHPS· The enrollee must request this change | · Date enrollment request was received· Name of the health plan the enrollee is requesting· Any medical bills from past months that are not being covered by FFS |
Plan Change – Change Option Available – Edit Prevents Enrollment | · Use the instructions in the Edits page in the MMIS User Manual to attempt to resolve the edit.· If the edit cannot be resolved submit an HPEN ticket with the required information. | · Provide which change option is available· Name of the health plan the enrollee is requesting· Full text of the edit |
Plan Change – Continuity of Care Change Request | · Some continuity of care issues can be resolved through the ombudsperson office. · Refer to Ombudsperson for Public Managed Health Care Programs for information on what they can do and when to call them. · If the ombudsperson office is unable to assist, submit an HPEN ticket and include the information gathered. | · Which provider is the enrollee requesting to go to?· Is the provider available in the enrollee’s current health plan?· Has the health plan been contacted to discuss if they will cover the service or location?· Was a referral requested from the health plan or clinic?· What service is the enrollee having difficulty obtaining?· What is the medical problem?· How long has the enrollee been receiving treatment for this condition with the provider they are requesting; and how much longer is it estimated that the treatment course will need to continue?· Name of the health plan the enrollee is requesting.· When does enrollment in the new plan need to begin?· Has the office of the ombudsperson been contacted? |
Plan Change – Good Cause Change Request | · Use the instructions in the Changing Health Plans in the MHCP managed care manual.· The enrollee should work with the health plan to resolve the issue. If they cannot come to a resolution, send an HPEN ticket. | · What services is the enrollee seeking?· Is the enrollee experiencing poor quality of care, lack of access to services, or lack of access to providers?· Has the health plan been contacted? – What was their response?· Name of the health plan the enrollee is requesting.· When does enrollment in the new plan need to begin?· Has the office of the ombudsperson been contacted? |
Plan Change – Reenrollment | · An enrollee has a break in eligibility greater than 2 months.· An enrollee has a change in major medical program.· An enrollee is disenrolled from a health plan for longer than 12 months.· The enrollee must request this change. | · Date enrollment request was received· Name of the health plan the enrollee is requesting |
Plan Change – Service Area Ending | · Use instructions in the Changing Health Plans in the MHCP managed care manual. · If a plan stops providing services in the enrollee’s county, the enrollee has 60 days from the first day of enrollment into a new plan to make a change. | · Date enrollment request was received· Name of the health plan the enrollee is requesting |
Reenrollment – MSHO, MSC+, or SNBC | · The enrollee’s MA eligibility is closed and is reopened within 90 days.· Or the enrollee’s MA eligibility is reopened retroactive to the closure date so there is no break in coverage. | · Date enrollment request was received· Name of the health plan the enrollee is requesting Note: An enrollment form is not required. |
Reprinting Notices | If reprinting a managed care notice for an appeal: · Complete the steps on the Reprint Managed Care Notice page in the MMIS user manual. · Request the notice be sent to the county. | · Notice type and the reason for reprinting the notice· The agency requesting a reprint must enter a case note in MMIS stating that the agency entered a request for a notice reprint on the RNOL screen. |
RTRK issue | · Use the instructions in the RTRK Screen or Tracking Criteria section of the MHCP managed care manual.· If a processing entity enters the wrong contact type, submit a HPEN ticket to request that the tracking span be deleted and a new span be added. Do not overwrite the existing span.· Send an HPEN ticket to request a reset of the 30-day counter on the RTRK screen in MMIS. | · Correct contact type· If the 30-day counter needs to be reset |
Security Error | · Worker is trying to update Health plan enrollment and receives a security edit in MMIS.· Worker doesn’t have the correct security level.· Case was transferred incorrectly.· Review SECURITY ERROR – NO ACCESS PERMITTED in MMIS manual for how to correct the error. · Send an HPEN to make changes to health plan enrollment.· This is not the same as a RECIPIENT LOCKED BY or CASE LOCKED BY edit message. | If health plan enrollment needs to be edited, send an HPEN ticket with the following information: · Full text of the edit· Explanation of what actions were taken when the error or edit occurred· Explanation of the health plan enrollment changes that need to be made· DHS cannot override RECIPIENT LOCKED BY or CASE LOCKED BY edit messages. Do not send a ticket. Try again later. The case may not be accessible under the change mode for the remainder of the day. The lock will clear overnight. |
Service Location Issue | · The service location county does not match the county that is attempting to make an update. · To change a service location, look up the exact edit in the Edits page in the MMIS user manual and send and HCESS ticket as directed. | If health plan enrollment needs to be edited, send an HPEN ticket with the following information: · Full text of the edit· Explanation of what actions were taken when error or edit occurred· Case owner or service location · Explanation of the health plan enrollment changes that need to be made |
System error | Use this to report a broad system defect, not an edit on a specific case or enrollee. Ex: TA exclusion error, RTRK error. | · Explain issue and provide relevant details. |
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