Frequently asked questions

In a coordinated effort to reduce fraud, waste and abuse in Minnesota’s Medicaid program, Governor Tim Walz announced on Oct. 29, 2025, a new process for the Minnesota Department of Human Services (DHS) to review claims for certain Medicaid benefits and services before they are adjudicated. Refer to the Governor Walz Orders Third-Party Audit of Medicaid Billing at DHS press release for more information.

Optum, a third-party vendor, will oversee the new pre-payment review process and will start by reviewing fee-for-service claims for 14 specific benefits and services that were identified as high-risk. Optum will verify that billed services were necessary, correctly documented and provided before DHS makes payments. 

We have identified the following 14 benefits and services 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

The new pre-payment review process does not change what has been and remains as MHCP’s mandated claim review timeframes: 

• MHCP has 30 days to pay or deny clean 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, 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. 

We are working with Optum on a regular interval to review any suspended fee-for-service claims for the 14 high-risk benefits and services and will continue to adjudicate claims timely and efficiently without compromising needed review. DHS is not holding all submitted claims for the 14 high-risk benefits and 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.

The pre-payment review will be an ongoing and permanent new process for DHS as fee-for-service claims come in and before provider payments go out. We are implementing this new process for fee-for-service claims only. Additionally, this new safeguard will be tied to services, not provider types.

No, MHCP is not pausing or holding payments to all providers. We are beginning with a specific list of 14 high-risk benefits and services and all claims within the identified benefits and services will be subject to pre-payment review. We are implementing this process for fee-for-service claims only.

The pre-payment review process is scheduled to start the beginning of December 2025.

In partnership with Optum, we are finalizing the pre-payment review process and are committed to keeping providers informed with timely updates as soon as they are available. Providers should check the following often for the latest updates. 

• Frequently asked questions – Pre-payment review process for Minnesota Health Care Programs fee-for-service claims webpage
• MHCP provider news and updates webpage
• MN–ITS mailbox

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.

The new pre-payment review process does not change what has been and remains MHCP’s mandated claim review timeframes: 

• MHCP has 30 days to pay or deny clean 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, 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. 

While we are working within the same claim review timeframes that we have been, there may be processing delays compared to previously submitted claims. DHS is not holding all submitted claims for these 14 Medicaid services for 90 days. Some submitted claims may pay as they have previously; some could be suspended for up to 90 days and some may be denied.

MHCP is committed to continue to meet the mandated claim review timeframes.

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 PDF 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.

Yes, providers should review their remittance advice to check on claim status. Refer to the How to read your remittance advice webpage for more information.

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.

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, or claims with attachments. 

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

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

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

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 CFSS services.

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

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.