CurrentUCarePolicy N/A

Advance Recipient Notice of Non-covered Service/Item

Forms and instructions for informing Minnesota Health Care Programs (MHCP) recipients when a service or item is not covered and obtaining recipient acknowledgment and payment agreement; applies to MHCP providers and recipients in Minnesota.

Policy Summary

PayerUCare

PolicyAdvance Recipient Notice of Non-covered Service/Item

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen a service/item requires authorization, request authorization through the MHCP medical review agent; if authorization is denied (other than billing error or lack of documentation), provider may bill recipient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form used to document recipient acknowledgement

multiplelisted reasons/services not covered (examples and exclusions)

1phone number for member help/translation services

do not bill MHCPcircumstances where providers must not bill recipient

Non-covered Services and Billing Restrictions

Non-covered services billing criteria and restrictions

Services/items that MHCP does not cover and the rules providers must follow before accepting payment from a recipient:

MHCP does not cover the following (examples): health services; services when a physician's order is required but not obtained; services not in the recipient's plan of care, individual treatment, education or service plan; services of lower quality than prevailing community standard (providers of such low-quality services must bear the cost); non-emergency services provided without full knowledge and consent of the recipient or legal guardian; services provided outside the United States or by providers whose financial institutions/entities are located outside the U.S.; services provided by practitioners outside their scope of practice or without appropriate credentials; missed appointments (do not bill MHCP recipients for missed appointments); reversal of voluntary sterilizations; services primarily for cosmetic purposes; vocational or educational services (including functional evaluations or employment physicals) except individual education plan–related services.

Provider requirements to accept payment from a recipient for a non-covered service/item (all must be met): the recipient is not enrolled in the restricted recipient program OR the recipient is enrolled in the restricted recipient program and the provider is not one of the provider types designated for the recipient's health care services; the provider reviewed with the recipient the service limits, reasons the service/item is not covered, and available covered alternatives; the provider obtained a recipient signature on the Advance Recipient Notice form.

Policy Summary

PayerUCare

PolicyAdvance Recipient Notice of Non-covered Service/Item

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization and third-party payment rules (all must be met): provider must request authorization/seek payment from other insurance or Medicare before requesting authorization/payment from MHCP or the recipient; when a service/item requires authorization, request authorization through the MHCP medical review agent; if authorization is denied for other than a billing error or lack of documentation, the provider may bill the recipient.

Billing prohibitions — do not request payment from the recipient for the following (all apply): a service that requires authorization unless authorization was denied as not medically necessary and the provider has reviewed all other therapeutic alternatives with the recipient; a service MHCP denied for reasons related to billing requirements; standard shipping/delivery and setup of medical equipment or supplies; services included in the recipient's long term care per diem; more than the provider's usual and customary charge for the service/item; the difference between what MHCP would pay for a less costly alternative and the upgraded service provided.

If MHCP pays: If MHCP makes any payment, provider may bill the recipient only for amounts designated as cost-sharing or spenddown.

Form and documentation requirements: the form must be used to record recipient and provider information, a description of the non-covered service/item (and code if available), reason not covered, alternate covered services, estimated cost and terms of payment, and obtain recipient signature prior to billing.

Prescriptions and excluded uses: do not use this form for controlled substance prescriptions, gabapentin or tramadol (see MHCP Advance Recipient Notice of Noncovered Prescription (DHS-3641)).

Definitions (for provider guidance): Upgrade — not a separate part of a service/item; an increased, newer or more advanced version of its base (e.g., power wheelchair is an upgrade of a manual wheelchair); Add-on — a separate part added to enhance a service/item (e.g., add-on basket to a walker).

Coding for Non-covered Items

Non-covered item coding fieldmixed

Field present on form to record non-covered service/item description and code if available

Authorization, Billing, and Coordination Responsibilities

Billing Rule

Third-party Payment / Coordination Required

You must request authorization/seek payment from other insurers or Medicare before requesting authorization or payment from MHCP. If another payer (including Medicare) may be responsible, providers must pursue that coverage first.

Seek payment/authorization from third-party insurers or Medicare prior to MHCP.
Do not bill MHCP or the recipient until other responsible payers have been pursued.

Denial Risk

Authorization and Billing After Denial

When a service requires authorization, request it through the MHCP medical review agent. If authorization is denied for reasons other than a billing error or lack of documentation, you may bill the recipient. Do not bill the recipient for services that require authorization unless authorization was denied as not medically necessary and you have reviewed all therapeutic alternatives with the recipient. Also do not bill the recipient for items MHCP denied for billing-related reasons, standard shipping/delivery/setup of equipment or supplies, services included in a long-term care per diem, charges above your usual and customary fee, the difference between MHCP-paid less-costly alternatives and an upgraded service, or for controlled substance prescriptions, gabapentin, or tramadol (use DHS-3641 instead). If MHCP makes any payment, you may bill the recipient only for amounts designated as cost-sharing or spenddown.

Request authorization through the MHCP medical review agent when required.
If authorization is denied (not due to billing error or missing documentation), you may bill the recipient after reviewing alternatives.
Do not bill the recipient for services requiring authorization unless denial was for not medically necessary and alternatives were reviewed.
Do not bill the recipient for MHCP denials related to billing requirements.
Do not bill for standard shipping, delivery, or setup of medical equipment/supplies.
Do not bill for services included in the recipient's long-term care per diem.
Do not bill more than your usual and customary charge or the difference when MHCP pays for a less costly alternative.
If MHCP pays, bill the recipient only for cost-sharing or spenddown amounts.
Do not use this form for controlled substance prescriptions, gabapentin, or tramadol — see MHCP Advance Recipient Notice of Noncovered Prescription (DHS-3641).

Term Definitions

Upgrade — definition

TermUpgrade

DefinitionAn upgrade is not a separate part of a service/item; a service/item that is an increased, newer or more advanced version of its base.

ExamplesA power wheelchair is an upgrade of a manual wheelchair; a CT scan is an upgrade of an x-ray.

Add-on — definition

TermAdd-on

DefinitionAn add-on is a separate part of a service/item; a service/item that is added to enhance a service/item.

ExamplesAn add-on basket is an add-on to a walker; an ultrasound modality is an add-on to a therapy.