Frequently asked questions

The pre-payment review process focuses on the benefit or services on the submitted claim, not the provider type. 

The Minnesota Department of Human Services is reviewing all fee-for-service claims for the following benefits that were identified as high-risk.

1. Adult Companion Services 
2. Adult Day Services
3. Adult Rehabilitative Mental Health Services 
4. Assertive Community Treatment 
5. Community First Services and Supports 
6. Early Intensive Developmental and Behavioral Intervention 
7. Housing Stabilization Services
8. Individualized Home Supports
9. Integrated Community Supports 
10. Intensive Residential Treatment Services
11. Night Supervision Services
12. Nonemergency Medical Transportation Services 
13. Recovery Peer Support 
14. Recuperative Care

Yes. Pre-payment review is a permanent part of the review process as mandated by Governor Walz. This means that we will conduct pre-payment review on every impacted claim even if we have reimbursed the provider for previously submitted claims. Refer to the Governor Walz Orders Third-Party Audit of Medicaid Billing at DHS press release for more information.

• When a provider submits a claim for any of the identified high-risk services, we will suspend the claim for pre-payment review. 
  • The time of suspension starts from the claim submission date in our system. We use the Julian calendar. Refer to How to read the payer claim control number PCN for more information. Refer to the MHCP billing resources webpage for the listed hyperlinks and other resources. 
• Optum, the third-party vendor, will run suspended claims through a series of analytics and share findings with DHS.
• If a claim is flagged for a specific analytic, we will review the claim.
  • We will notify providers if additional documentation is needed. Refer to the Documentation section for more information. 
• We will release unflagged claims for reimbursement in the following warrant cycle (two weeks later).

The warrant cycle is the two weeks before the electronic funds transfer (EFT) or the payment date you submit claims. The warrant cycle starts the date after claim cut-off and goes until the claim cut-off date. Review the 2026 payment and claim cut-off calendar for more information.

Yes, providers should review their remittance advice (RA) to check on claim status. Impacted claims will show a “suspended” status on the Provider Supplemental Data (RA02).Refer to the How to read your remittance advice webpage for more information.

Yes, you can check the status of any submitted claims in MN–ITS. Refer to the Checking Claim Status in MN-ITS (video) or Use MN–ITS Request Claim Status (276/277) to Check the Status of a Claim in the MN–ITS User Manual for information about how to check your claim status. These claims will display the following under claim information:

• Claim status category P2 and claim status 46 (X12 External Code List)

MHCP generates a PDF version of a remittance advice for each provider that includes all submitted claims for that warrant cycle, and indicates whether we have paid, denied or suspended each claim. Refer to the payment and claim cut off calendar for RA dates on the MHCP billing resources webpage.

Providers should refer to the Provider Supplemental Data (RA02) for suspended claims in their MN–ITS Mailbox Transaction Responses in the 835_PDF folder. For providers that receive their remittance advice via X12 835 Health Care Claim Payment/Advice, the X12 835 will only include information for paid or denied claims.

Providers and billers submitting X12 batch transactions to the Minnesota Department of Human Services may submit a Claims Inquiry Request (276 transaction) or refer to the PDF version of their RA for information about suspended claims.

No, MHCP is not pausing or holding reimbursement to all providers. We are suspending claims and holding reimbursement for all claims with an identified high-risk benefit or service for review. Refer to the high-risk benefits and services listed in the Which providers or services are impacted by the pre-payment review process? question for impacted claims.

No, MCOs are not included in the pre-payment review process – MCOs conduct their own pre-payment review. This pre-payment review process only impacts fee-for service claims.

Payment withholds are initiated by the Office of Inspector General (OIG) and OIG will notify providers if they are subject to a payment withhold. 

Refer to the “What is the new pre-payment review process and why is it happening” question for information about the process.  

The pre-payment review process will include all claims for PCA/CFSS services.

You should continue following your standard protocols; however, if you bill all services on one claim,  the claim will suspend. You may consider submitting the services on separate claims. This will ensure that any high‑risk services that suspend for review does not delay payment for the non‑high‑risk services.

If you have complex claims that have suspended for review before the implementation of pre-payment review, those claims will still go through the same process as before. Once the claim has been reviewed, the pre-payment review process will apply.

The pre-payment review process began late December 2025.

We expect that claims will be suspended for two weeks after the end of a warrant cycle to allow time for identifying any potentially improper payments. 

State law (Minnesota Statutes, 16A.124, subdivision 4b) gives MHCP the following amount of time to review claims before reimbursing providers; and the new pre-payment review process does not change these timeframes:  

• MHCP has 30 days to pay or deny clean claims (claims without attachments).
• MHCP has 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, claims with attachments). 

Additionally, the Minnesota Department of Human Services Commissioner has the legislative authority to suspend and perform a deeper analysis on any claims which may be potentially suspect for fraud, waste or abuse.

State law (Minnesota Statutes, 16A.124, subdivision 4b) gives Minnesota Health Care Programs (MHCP) 30 days to process clean claims (claims without attachments) 

Historically, providers may have received reimbursement immediately following the end of a warrant cycle, but moving forward, that timeframe may be up to four weeks because of the pre-payment review process for these high-risk benefits.

We understand this is an adjustment, and providers need to plan for how the new review process fits into their business operations because it will remain a part of our process going forward. Additionally, pre-payment review may expand to all Medicaid benefits.

Providers do not need to do anything different or submit additional documentation unless requested by the Minnesota Department of Human Services. We will drop a “request letter” in your MN–ITS mailbox (miscellaneous received, file type PREPAYDOCREQUEST) if we need more information from you about a specific claim. Follow the instructions in the request letter if you receive one.

We publish documentation requirements in the MHCP Provider Manual and associated Minnesota Department of Human Services webpages. We expect that providers will adhere to these requirements.

No, MHCP-enrolled providers cannot stop providing services to MHCP members. State law requires that providers continue to offer services to members as long as providers are enrolled with MHCP. We appreciate your dedication to serving our members and enrolling with us as a provider.

MHCP may terminate and unenroll providers if they stop offering services to MHCP members. Refer to Provider Requirements - Provider Participation Requirements – Rule 101 for more information on provider requirements. Refer to MHCP Member Evidence of Coverage for member rights.

Yes, MHCP members can still schedule appointments or services with MHCP-enrolled providers. 

MHCP-enrolled providers cannot stop providing services to MHCP members. State law requires that providers continue to offer services to members as long as providers are enrolled with MHCP.

MHCP may terminate and unenroll providers if they stop offering services to MHCP members. Refer to Provider Requirements - Provider Participation Requirements – Rule 101 for more information on provider requirements. Refer to MHCP Member Evidence of Coverage for member rights.

The Minnesota Department of Human Services will freeze new provider enrollments in the identified high-risk services and benefits. We are working with the U.S. Centers for Medicare & Medicaid Services (CMS) to implement the freeze, at which point the state will no longer accept new applications from businesses seeking to provide these services for a defined period of time. 

A start date for the freeze is not yet determined. The pause is initially slated to last six months. 

Currently enrolled providers can continue to serve members in the service areas they are already approved to provide. Additionally, this action does not freeze member enrollment. 

To ensure Minnesotans can receive critical services everywhere they live, the department will issue exceptions to add new providers where capacity is needed. Exceptions will require written approval from CMS.

We are working with CMS to develop the necessary operational processes and system updates, including determining how provider applications in queue will be handled. 

We will share more information as soon as it is available.

The pre-payment review process is intended to reinforce the existing requirements outlined in the MHCP Provider Manual, which all providers are expected to follow to ensure compliance with documentation and billing standards and minimize suspended claims. We currently offer provider training and issue biweekly provider news updates. 

Providers can also sign up to get email notices of revisions specific to the services you provide.

We continually update our policies and billing processes to reflect legislative changes. We will work to keep our vendors informed of any changes.