In a coordinated effort to reduce fraud, waste and abuse in Minnesota’s Medicaid program, Governor Tim Walz announced on Oct. 29 a new process for Minnesota Department of Human Services (DHS) to review claims for certain Medicaid benefits and services before they are paid. Read the news release on the governor’s office Press Releases webpage.
This new “pre-payment review” process will be overseen by a third-party vendor, Optum. For 14 specific services that have been identified as high risk, Optum will verify that billed services were necessary, correctly documented and provided before DHS makes payments.
Minnesota Health Care Programs has 30 days to pay or deny clean claims (without attachments), and 90 days to pay or deny complex claims (replacement claims, Medicare crossovers, third-party liability claims, claims with information in the notes or comment fields, or claims with attachments). The DHS Commissioner has the legislative authority to suspend and perform a deeper analysis on any claims which may be potentially suspect with regard to fraud, waste or abuse. There may be payment processing delays as we roll out this new pre-payment review process. We are working with Optum on a regular interval to review any suspended claims for these 14 Medicaid services and will continue to adjudicate claims timely and efficiently without compromising needed review. DHS is not holding all submitted claims for these 14 Medicaid services for 90 days. Some submitted claims could be suspended for up to 90 days and, of course, some of these claims may be denied.
DHS recognizes that payment delays have impacts on providers, and we are committed to processing claims as quickly as possible and within the mandated timelines. We appreciate your patience as we initiate and refine our new pre-payment review process. Please continue to provide services to MHCP members and submit your claims as you normally would. We are implementing this new process for fee-for-service claims only.
Pre-payment review will be an ongoing and permanent new business process for DHS as fee-for-service claims come in and before provider payments go out. Importantly, this new safeguard will be tied to services, not provider types.
For reference, here are the 14 high-risk benefits and services with a link to their Provider Manual sections:
- Adult Companion Services
- Adult Day Services
- Adult Rehabilitative Mental Health Services
- Assertive Community Treatment
- Community First Services and Supports
- Early Intensive Developmental and Behavioral Intervention
- Housing Stabilization Services
- Individualized Home Supports
- Integrated Community Supports
- Intensive Residential Treatment Services
- Night Supervision Services
- Nonemergency Medical Transportation Services
- Recovery Peer Support
- Recuperative Care
Continue to submit claims for these services based on information outlined in our MHCP Provider Manual and Community-Based Services Manual. If you have questions, contact the Provider Resource Center. (pub. 10/29/25, rev. 10/31/25)
