Frequently asked questions

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

Optum, a third-party vendor, will start by reviewing all fee-for-service claims for the following 14 specific benefits and services 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

Pre-payment review is a permanent part of the review process as mandated by Governor Walz. This means that DHS 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.

No, MHCP is not pausing or holding reimbursement to all providers. We are holding reimbursement for all claims with an identified high-risk benefit or service for review. Refer to the 14 high-risk benefits and services listed in the What providers or services are impacted by the pre-payment review process? question for impacted claims.

Yes, providers should review their remittance advice 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.

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. 

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 DHS may submit a Claims Inquiry Request (276 transaction) or refer to the PDF version of their RA for information about suspended 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.

The pre-payment review process began late December 2025.

State legislation 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, and claims in “suspended” status).

Additionally, the DHS 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. 

Providers may experience a difference in how quickly they get reimbursed because of the pre-payment review process. For example, a provider may have historically received reimbursement about every 14 days for billed services but the pre-payment review process may result in a longer timeframe, and up to the previously listed mandated timeframes, before reimbursement is received.

MHCP is required to pay or deny clean claims within 30 days; and complex claims within 90 days of receiving the claim. 

Clean claims are MHCP primary claims without attachments. Complex claims are replacement claims, Medicare crossovers, third-party liability claims, claims with information in the notes or comment fields, claims with attachments, and claims in “suspended” status.

Review the Prompt Payment in the Billing Policy Overview under Provider Basics in the MHCP Provider Manual for more information.

Providers do not need to do anything different or submit additional documentation unless requested by DHS. We will drop a “request letter” in your MN–ITS mailbox (miscellaneous received, file type PREPAYDOCREQ) if we need more information. Follow the instructions in the request letter if you receive one.

DHS publishes documentation requirements in the MHCP Provider Manual and associated DHS webpages. DHS expects that providers will adhere to these requirements. 

Attachments are documents that may be needed for some claims. Example of attachments include the following:

• If Medicare has been exhausted for inpatient hospital services, we require the Medicare explanation of benefits (EOB) as an attachment. 
• If we cannot price a durable medical equipment (DME) supply, a manufacturer’s suggested retail price (MSRP) document from the manufacturer is required. We will accept an invoice from the manufacturer If the MSRP is not available.

DHS continually updates its policies and billing processes to reflect legislative changes. DHS will work to keep our vendor informed of any changes.

Yes, providers can continue to provide services and care to MHCP members. MHCP members can still schedule appointments or services with MHCP-enrolled providers.

Providers should refer to enrollment pages in the MHCP Provider Manual and the MHCP provider news and updates webpage for the latest information.

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.

NEMT claims paid by DHS to counties or directly to providers may be delayed during the pre-payment review process.

Optum will review all NEMT claims, including those coming from counties. The review will ensure that all claims are consistent with applicable statutes and rules.

The report schedule will stay the same but claim payments could be delayed.

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.