Minnesota MN

MN Medicaid (Medical Assistance / MHCP) expresses prior authorization through the online HTML MHCP Provider Manual (Oracle UCM, dDocName-addressed pages), NOT per-service PDFs. PA splits THREE ways by who reviews: (1) FFS medical/service authorization -> Acentra Health, the designated medical review agent, via the Atrezzo provider portal (mhcp.acentra.com), fax/phone, using the 278 transaction / MHCP Authorization Form + medical-necessity documentation; (2) FFS outpatient prescription + physician-administered drug PA -> Prime Therapeutics (formerly Magellan), the prescription-drug PA agent, via the Minnesota Medical Assistance Portal (phone 844-575-7887, fax 866-390-2778, ePA); NOT a statewide pharmacy carve-out -- managed-care drug PA stays with each PMAP plan's PBM; (3) Managed care (PMAP) PA -> the member's PMAP plan (8 plans: Blue Plus, HealthPartners, Hennepin Health, Itasca Medical Care, Medica, PrimeWest, South Country Health Alliance, UCare) -- providers must contact the MCO directly. Criteria live as Manual sections with an Authorization subsection per service (Inpatient Hospital, Dental tables, Specialized Supplies & Equipment, Transplant code list, Cardiac MRI criteria, Rehab/Therapeutic criteria, Program HH dental). The general Authorization chapter (id_008925) lists special pathways: EIDBI, EMA Care Plan Certification, Home Care, Out-of-State, SUD nonresidential, Psychiatric Residential Treatment Facilities, investigational drugs, continuity-of-care. AUTHORITY = DHS publishes the manual; Acentra (medical) + Prime Therapeutics (drug) are the FFS review agents; MCOs own PMAP PA. BOT WALL: legacy www.dhs.state.mn.us (Oracle UCM) + mn.gov/dhs sit behind Radware Bot Manager / ShieldSquare. Plain HEAD/fetch and default headless Chromium get captcha-walled (existing docs 248/249 captured only the captcha page). dDocName pages render fine through a stealth Playwright context (navigator.webdriver masked, real UA, en-US/America-Chicago); the numeric dID= form returns empty -- use dDocName=. Harvested 11 rendered-HTML authorization/criteria artifacts to Corsair.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: ?. Next due: 2026 RFP expected for F&C re-procurement (TBD). Contracts extended through: 2026-12-31 (F&C); 2027-12-31 (MSHO/MSC+/SNBC option years).

## 1. How MN requires PA Minnesota Medicaid (Medical Assistance) requires prior authorization (PA) for specific services and drugs to ensure medical necessity and appropriate utilization. The state's hybrid, MCO-dominant model means some services are carved out while others fall under MCO oversight. Key points: - **Inpatient Hospital Authorization (IHA):** Required for certain admissions, such as those to Medicare rehabilitation distinct units. Medical review agents determine medical necessity based on patient records and clinical decision tools. - **Dental Services:** Prior authorization required for specific dental services like radiographs, imaging, and restorations. Documentation must meet ADA recommendations and include comprehensive treatment plans and clinical notes. - **Specialized Equipment and Supplies:** Requires a doctor's order unless covered by Medicare or other insurance. Specific item descriptions, costs, and rationales are necessary. - **Cardiac MRI:** Prior authorization required, with specific criteria for scanner specifications and indications. - **Transplant Procedures:** Authorization is mandatory before out-of-state services are rendered, requiring documentation of diagnosis, proposed treatment, and adherence to Medicare, UNOS, and FACT requirements. - **Rehabilitation (PT/OT/SLP):** No prior authorization required since July 1, 2013 (audiologist services may require authorization above an annual threshold; post-payment review possible). ## 2. How MN publishes and reports PA Minnesota publishes its PA criteria primarily through the Minnesota Health Care Programs (MHCP) Provider Manual and specific policy documents: - **Provider Manual:** Detailed PA requirements for various services (inpatient hospital authorization, dental services, specialized equipment, cardiac MRI, etc.). - **Policy Documents:** Specific PA criteria appear in documents such as "MN Authorization General" and "MN Authorization Drug," with step-by-step instructions and required documentation. - **Online Access:** The MHCP Provider Manual is available online (DHS dynamic-conversion / dDocName pages), though some entry points return CAPTCHA/bot-detection challenges. ## 3. MN's CMS-0057-F and PA-reform compliance posture Minnesota's CMS-0057-F posture is not directly evidenced in the source documents. (Note: CMS-0057-F is a federal final rule, not a state waiver application — the local model's "Minnesota submitted a CMS-0057-F waiver application" claim was a fabrication and is removed.) Relevant structural facts that bear on PA reform: - **Behavioral Health Carve-Out:** Mental health (MH) services are carved into MCOs; chemical-dependency services are county-administered via 1915(b)(4) Community Care and CCDTF programs. - **Long-Term Services and Supports (LTSS):** LTSS for individuals under 65 are partially carved out to FFS; those for seniors 65+ are carved into MCOs via MSHO (Minnesota Senior Health Options) and MSC+ (Minnesota Senior Care Plus) programs. Minnesota is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Minnesota. The local model's earlier "Wisconsin Integrated System for Recovery" expansion was a hallucination and is incorrect.) No WISeR participation should be inferred for MN. ## 4. How MN runs its own program Minnesota's Medicaid program operates through a hybrid, MCO-dominant model with specific carve-outs: - **Managed Care Organizations (MCOs):** MCOs manage health plans under contracts that typically run one year with up to five option years. Current contracts extend through December 31, 2026 for Families & Children (F&C) programs and December 31, 2027 for MSHO/MSC+/SNBC programs. - **Behavioral Health Services:** MH carved into MCOs; chemical-dependency services county-administered via CCDTF programs. - **LTSS:** Under-65 LTSS partially carved out to FFS; seniors 65+ managed by MCOs through MSHO/MSC+. - **Pharmacy Services:** Pharmacy benefits are managed with PA for certain drugs (medical-necessity documentation and step-therapy; submission via phone, fax, or electronic PA). ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Multi-Vendor Review:** PA review involves a medical/service-authorization agent (Acentra Health), a drug-review vendor (Prime Therapeutics), and per-MCO review for managed-care enrollees. (Vendor roles per source documents; confirm against current contracts.) - **Behavioral Health Carve-Out:** MH carved into MCOs while chemical-dependency services are county-administered, reflecting tailored care management. - **Transplant Authorization:** Specific criteria and documentation requirements demonstrate a rigorous medical-necessity approach aligned to national standards. ### Missing/Uncertain: - **Gold Card Law Details:** Unspecified in the source documents. - **Foster Care Program Details:** No specific foster-care MCO program described. - **Effective Dates for Some Policies:** Many PA documents specify effective dates; some (e.g., a dental PA chart) do not. These patterns and gaps highlight the complexity of Minnesota's Medicaid PA system and the need for clear documentation across service areas.