Purpose

To set up a prepayment review process for Minnesota’s Medical Assistance (Medicaid) claims when a provider type is designated as high-risk by federal or state authorities, with the goal of reviewing claims before payment to reduce potential improper or high-risk payments.

Key provisions and how it works

• Prepayment review triggers: The commissioner must establish prepayment review for fee-for-service claims when a provider type is designated high-risk (under a specific Minnesota statute) and when a covered service is designated high-risk, with the exception of claims from the Indian Health Service.
• Authority to use other triggers: The commissioner can also use prepayment review in other situations if required by the Centers for Medicare and Medicaid Services (CMS).
• Time to set up: Once a high-risk designation is in place, prepayment review must be implemented within 15 days and run for up to 24 months from the start date.
• Compliance with federal rules: The review must follow timely processing requirements found in federal regulations (CFR title 42, section 447.45).
• Review of past claims: Before ending the prepayment review, the commissioner must review all fee-for-service claims submitted by providers under review during the 24 months before the designation.
• Enrollment during review: Providers subject to prepayment review can continue enrolling new clients during the review period.
• Notice before starting: At least 10 days before starting the prepayment review, the commissioner must notify affected providers and the chairs and ranking minority members of the relevant legislative committees. The notice should include which provider types or services are covered, the basis for the review, and the start date and expected duration.
• Report to the legislature after the review: Within 60 days after the review ends, the commissioner must report to the same legislative committees. The report must include:
  • A summary of any sanctions imposed on providers under a related sanctions law (section 256B.064).
  • Recommendations for modifying or ending the high-risk services or the reviewed provider types, if needed.
• Non-expiration: This provision is stated not to expire.

How this changes current law

• Adds a formal requirement for prepayment review when high-risk provider types or high-risk services are designated, including timelines, notice, and reporting duties.
• Requires a retrospective review of claims from the 24 months before designation before ending the review.
• Establishes a public notice and legislative reporting process, and preserves provider enrollment during the review.

Practical impact

• Providers and claims that fall into high-risk categories may face temporary prepayment checks before payment is issued.
• The state must carefully document and report on the impact, including any sanctions used and whether the high-risk designations should continue.
• The process includes transparency with providers and state lawmakers, and it does not block new client enrollment during the review.

Significant changes to existing law

• Introduces a formal prepayment review mechanism tied to high-risk designations, with explicit implementation timelines, notice requirements, and a mandatory post-review legislative report.
• Adds a protection that enrollment in the program can continue for new clients during the review period.
• Specifies non-expiration of the review provision.

Relevant Terms - prepayment review - fee-for-service claims - provider type - high-risk designation - Center for Medicare and Medicaid Services (CMS) - Indian Health Service - covered services - timely processing of claims - CFR 42 447.45 - Minnesota Statutes section 256B.044 - sanctions (section 256B.064) - commissions/commissioner - notice to providers - legislative committees (health and human services policy and finance) - report to the legislature - start date and duration of review - post-review evaluation