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MHCP (Minnesota Health Care Programs): The Medical Assistance (MA) Program, MinnesotaCare, Behavioral Health Fund (BHF) Program, Prepaid Medical Assistance Program (PMAP), home and community-based services under a waiver from CMS, or any other DHS administered health service program. Minnesota Rules 9505.0070 Third-Party Liability .D"NlI0kb`%*@Hnf`bd|r(A0@ '" Record retention in contested cases. endstream endobj startxref HS]O0}_qd_TILXv]@O.K{=p> X1R)MD*u 7p\y D2a\&bh1hq{.uNj`)9T@*pU&T!Bz $2ToWIGtfN.[4y7n1MDP0j=g*E^ X2SYJsOJ=I!J]D]KRihmOS-f&nR#wa{:f$f? Documentation required for every child in family child care Documentation family child care license holders must maintain Additional family child care license holder forms and information 42 CFR 455 Program Integrity: Medicaid Prior Authorization Form for Early Intensive Developmental & Behavioral Intervention (EIDBI) DHS, at its own expense, may photocopy or otherwise duplicate any health service or financial record related to a health service for which a claim or payment is made under a MHCP program. DENC - Detailed Explanation of Non-Coverage Form For assistance, refer to the Instructions to Complete the PCA Technical Change Request (DHS-4074A), DHS-4074C. We would like to show you a description here but the site won't allow us. ! Form Details: Released on January 1, 2012; They must also submit a new Provider Agreement, a Disclosure of Ownership and Control Interest Statement for Participating Providers (DHS-5259) (PDF), and any other required enrollment documentation to Provider Enrollment no later than the effective date of the sale or transfer. - Enrollment with Minnesota Health Care Programs (MHCP) Forms for family child care providers / Minnesota Department of Human Minnesota Statutes 256B.0625 Covered Services Requirements regarding the need for a referral, or which days are available for treatment, etc., are legitimate requirements for MHCP recipients only if they are also applied to other clients. Furthermore, a provider who has such restrictions or criteria shall disclose the restrictions or criteria to DHS so DHS can determine whether the provider complies with the requirements of this subpart.". BG[uA;{JFj_.zjqu)Q Under Minnesota law all enrolled providers are required to report all suspected maltreatment including abuse, neglect or financial exploitation of a vulnerable adult to the common entry point following the requirements in Minnesota Statutes 626.557, subd. Beginning on August 1, 2018, the provider may have to call the Office of Medical Assistance Programs, Provider Enrollment at 1-800-537-8862 to request a paper application if the PDF version of the application is no longer posted on the DHS Provider Enrollment website. The latest edition provided by the Minnesota Department of Human Services; Compatible with most PDF-viewing applications. All information is provided in good faith, however, we make no representation or warranty of any kind regarding its accuracy, validity, reliability, or completeness. [{8R&c*nF\JY3(=xEELL Mental Health Outpatient Forms utilized for the following codes: H2012, H2017, H0034, 90882, and H0019.