*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: June 1, 2012 |
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24.10.05.10 - Designated Provider Option |
Archived: June 1, 2016 (Previous Versions) |
Some clients may choose to pay their monthly spenddown amount to one provider each month. This is referred to as the Designated Provider Option.
Assigning and Changing Designated Providers.
Apply the information in this section to monthly medical spenddowns. For information about using a designated provider for a long-term care (LTC) spenddown or waiver obligation, see Long-Term Care (LTC) Spenddowns and Waiver Obligations.
Note: Clients who receive their services through the Minnesota Senior Health Options (MSHO) cannot use the designated provider option.
Clients may choose the designated provider option if they meet all of the following conditions:
l The client has an monthly spenddown.
l The client receives one of the following types of services:
n Personal Care Attendant (PCA) services.
n Child-welfare targeted case management services.
n One of the following home and community-based waivers:
m Community Alternatives for Disabled Individuals (CADI).
m Brain Injury (BI).
m Community Alternative Care (CAC).
m Developmental Disabilities (DD).
m Elderly Waiver (EW) (Most EW clients are enrolled in MSHO and therefore, are not able to use the designated provider option.).
l The client’s recipient amount after deducting allowed medical expenses such as health care premiums, Medicare premiums and the remedial care expense deduction is greater than $0.
l The client is the only member of the MA household with a spenddown.
l The client’s health care expenses from one provider will satisfy the entire recipient amount.
Note: Providers enter the amount of monthly services costs provided to the client in the Designated Provider section on the Request for Designated Provider Agreement (DHS-3161). Use this information to ensure that the provider will be or is providing services that equal or exceed the client's recipient amount each month. The client is expected to continue to satisfy the spenddown with the same designated provider.
l The client is willing to pay the recipient amount to the designated provider at the time of service.
Clients who meet all of the criteria for use and choose to use the designated provider option must:
l Designate the chosen provider on the Request for Designated Provider Agreement (DHS-3161).
The MMIS User Services Help Desk monitors all designated provider cases to make sure:
n The provider submits bills within three months.
n The client incurs enough expenses to meet the spenddown.
l Sign and give the Request for Designated Provider Agreement (DHS-3161) to the provider.
l Report designated provider changes before the provider service begin date.
Note: MMIS will not apply the new designated provider bills to the client’s current spenddown amount if the client does not report the change timely. Clients must report changes to the designated provider 30 days before the change.
Designated providers are required to complete the Designated Provider section of DHS-3161 and fax the completed form to the county indicated on the form.
l Providers cannot refuse to be designated providers.
l Providers must indicate the amount of monthly services being provided to the client each month.
l Providers must bill DHS for the services within three months of providing the service.
l DHS will pay claims according to claims policy.
Each provider has a unique designated provider number. The designated provider number is used in the claims process. An accurate designated provider number assures that claims are paid properly and applied to the client’s spenddown correctly. The designated provider will indicate on DHS-3161 the National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) number under which the services will be billed.
To assign the unique designated provider number:
l Use the NPI or UMPI number and, if applicable, the taxonomy code, along with the address of the provider from the Designated Provider section of the DHS-3161.
l Access information through MMIS Provider subsystem. If the designated provider is part of a consolidated provider group, choose from the list based on the provider’s address. See MMIS User Manual, Designated Provider for more information.
Assigning and Changing a Designated Providers
Enter a designated provider number in MMIS:
l For applicants: for the month of application and any retroactive month in which the client is eligible.
l For enrollees: for the next available month. It cannot be entered for the current or prior months.
Remove the designated provider number for the next available month when the client is no longer using the designated provider option.
If an incorrect provider was entered as the designated provider on a medical spenddown, correct the designated provider for the next available month. The county may collect the spenddown from the recipient. Send the payment labeled Designated Provider Error along with the recipient's PMI number and the amount for each month to:
MN Department of Human Services
Provider and Member Services
Benefit Recovery - Spenddown Errors
PO Box 64994
St. Paul, MN 55164-0994
Document any collection efforts or amounts collected in MMIS case notes.
Clients can meet their spenddown using a provider other than the designated provider only in emergencies. Clients must report the emergency use within five days of incurring the expense. The county may collect the spenddown from the client and send the payment labeled Designated Provider-Emergency Use of Different Provider along with the client's PMI number to:
MN Department of Human Services
Provider and Member Services
Benefit Recovery - Designated Provider-Emergency Use of Different Provider
PO Box 64994
St. Paul, MN 55164-0994
Document any collection efforts or amounts collected in MMIS case notes.
MMIS sends designated providers a monthly notice which includes the client's name and the recipient amount the designated provider must collect from the client.
Note: A separate notice is sent for each client.
When a client's health care eligibility is closed, MMIS sends the designated provider a notice indicating the date the provider should stop collecting the recipient amount from the client.
MMIS also sends a notice to the designated provider when the client's recipient amount changes.