Request for an MHCP Member’s Claims Payment History (DHS-2133)

Follow these instructions to complete the DHS-2133 to request a claims-payment history for Medical Assistance (MA) estate recovery.

1. Enter the MA member’s information under Step 1

Enter the MA member’s first, middle and last name; date of birth; and eight-digit member ID number (Person Master Index [PMI] number).

Please note: If you do not enter all eight digits of the PMI, including zeros, there will be a significant delay in the processing of your request.

2. Enter the date of your request under Step 2

Enter the date you email the request to DHS.

3. Indicate that your request is for MA estate recovery under Step 3

For MA estate recovery, do the following:

· Check the box that says “Request for Medical Assistance (MA) estate recovery.”

· Indicate whether the MA member has died.

· If the MA member has died, select “Yes” and enter the member’s date of death.

· If the MA member has not died, select “No.”

· Indicate whether the MA member lived or is living in a medical institution before age 55 by selecting “Yes” or “No.” (This question is important because, if the member did live or is living in a medical institution before age 55, you cannot collect unless DHS has an MA lien filed against the member’s real property.)

· If the member lived or is living in a medical institution before age 55, and DHS does not have a lien in place, then to collect payment for services received before age 55, the member’s treating physician, advanced practice registered nurse or physician assistant must sign a verification form stating that the member cannot be expected to return home from the medical institution.

· If the member ever returns to the community, payment for services received before age 55 cannot be recovered.

· DHS is working to update its eDocs forms to provide local agencies with a method for receiving physician verification of permanent institutionalization outside the MA lien process.

Note: Step 3 has a second checkbox, for requesting a claims payment history for purposes other than MA estate recovery. Do not check this box or enter any data in the fields following it when requesting a claims payment history for MA estate recovery. Do not enter begin or end dates, major programs, or report types for MA estate recovery purposes.

4. Enter your information under Step 4

Enter your first name, last name, phone number, email address, and mailing address. Also enter your agency’s name and county code.

5. Email the completed form or questions about the form to DHS via secure email at DHS.SRUfax@state.mn.us