Provider Resources

Reference Material | FAQs | Forms

Reference Material

MHCP Manual

MN Department of Health Training on Smart Goals

https://www.health.state.mn.us/communities/practice/resources/training/1601-objectives.html

Level of Care Assessment for Day Treatment, PHP, IRTS, IRMHS, ITFC, ARMHS, and ACT

https://mn.gov/dhs/assets/TCM.Necessity%20of%20Care%20%20FAQs%20%28002%29_tcm1053-560965.pdf

Fraud & Abuse

Medicaid fraud is a deliberate withholding or hiding of information or giving false information to get Medicaid or FAMIS Plus benefits. Medicaid fraud also occurs when a provider bills Medicaid for services that were not delivered to a Medicaid recipient, or if a recipient shares his/her Medicaid number with another person to get medical care. Anyone convicted of Medicaid fraud in a criminal court must repay the Medicaid program for all losses (paid claims and managed care premiums) and cannot get Medicaid for one year after conviction. In addition, the sentence could include a fine of up to $25,000 and/or up to 20 years in prison. You may also have to repay the Medicaid program for any claims and managed care premiums paid during periods you were not eligible for Medicaid due to acts not considered criminal.

Frequently Asked Questions

Dental - General FAQ

Forms

Many of Acentra's documents are provided in PDF Format.

Chiropractic

DHS-4878 Chiropractic Authorization Form

Form is utilized for the following: 98940-98942

CMDE/EIDBI

DHS 3806A-Instructions for the MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Request form

Description: Service providers should use this instructions sheet as they complete the DHS-3806 authorization form for EIDBI services that exceed the service limit threshold (e.g., additional CMDE in a calendar year). - Posted 11/23/22

DHS-3806 Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization

Service providers use this form to request authorization for EIDBI services that exceed the service limit threshold (e.g., additional CMDE in a calendar year, additional coordinated care conference in a calendar year, etc.).

Acentra Health Service Authorization Check ITP Posted 9/23/24

Acentra Health Administrative Submission Checklist CMDE Posted 9/23/24

Dental

DHS- 3538 Dental Implants

-Posted 11/23/22

DHS-6119-ENG TMD Dental Treatment Authorization Form

DME

DHS 4315 (DME) Mobility Devices

Form is utilized for the following: K0001-K0009,K0800-K0891,K0898,E1161,E1231-E1239, E1031-E1039, K011-K0014. Posted - 11/23/22

DHS 4370 (DME) Enclosed Medical Bed

Form is utilized for the following: E1399,E0316,E0328,E0329. Posted 11/23/22

DHS - 4045 (DME) Specialized Wound Therapy