Purpose

Establish a process for prepayment review of certain Minnesota Medical Assistance (MA) claims. The review would occur when a provider type is designated as high-risk and a related service is designated as high-risk by the commissioner or the Centers for Medicare and Medicaid Services (CMS). The goal is to scrutinize claims before payment to reduce potential improper payments while allowing continuation of enrollment for new clients during the review.

Main provisions

• Prepayment review triggers: The commissioner must start prepayment review for submitted medical assistance claims for (a) a provider type designated high-risk under Minnesota Statutes 256B.04, subdivision 21, paragraph j, for fee-for-service claims within that category, and (b) a covered service designated high-risk for fee-for-service claims by any provider except the Indian Health Service (IHS). CMS designation can also trigger prepayment review in other circumstances.
• Duration and timing: Implement prepayment review within 15 days of the high-risk designation, for up to 24 months from the date the review begins.
• Compliance with timely processing: The review must comply with timely processing of claims requirements from 42 U.S.C. 447.45 (the federal regulation cited as Timely Processing of Claims).
• Prior claim review: Before ending the prepayment review, the commissioner must review all fee-for-service claims from the 24 months before the designation (the 24-month look-back).
• Enrollment during the review: Providers already enrolled and subject to prepayment review may continue enrolling new clients during the review period.
• Notice to stakeholders: At least 10 days before starting the prepayment review, the commissioner must notify enrolled providers and the Chairs and Ranking Members of the relevant legislative committees. The notice must list the provider types or services affected, explain the basis for the review, and identify the start date and expected duration.
• Reporting to the legislature: Within 60 days after the review ends, the commissioner must report to the Chairs and Ranking Members of the health and human services policy and finance committees. The report must include a summary of any sanctions imposed under section 256B.064 and recommendations for modifying or terminating the covered services or provider types subject to the review.
• Non-expiration: The reporting requirement in this section does not expire.

How it changes existing law

• Creates a new mechanism (256B.044) to impose prepayment review on MA claims under specific high-risk designations.
• Aligns Minnesota’s MA claim review process with federal oversight by referencing CMS designations and federal timely processing requirements.
• Adds explicit notice and reporting duties to inform legislators and providers and to document sanctions and potential policy changes.

Implementation and oversight details

• Triggering designations: The process relies on federal and state high-risk designations for provider types and services.
• Scope: Applies to fee-for-service MA claims; excludes IHS-related service claims from the high-risk service designation triggering prepayment review.
• Duration: Up to 24 months per designation, with review timing and look-back requirements.
• Documentation and transparency: Requires advance notice to stakeholders and a post-review report with sanctions and policy recommendations.

Potential impact

• Providers in designated high-risk categories may experience additional checks before payment, which could affect cash flow and administrative workload.
• The state gains a formal, time-limited tool to address potentially improper MA payments and to guide future policy on high-risk services or provider types.
• Engagement with lawmakers and providers is codified through required notices and post-review reporting.

Notable limitations or safeguards

• The Indian Health Service is explicitly excluded from the high-risk service designation in the triggering language.
• The review is limited in duration (up to 24 months) and includes a look-back period to ensure prior activity is considered.
• Enrollment of new clients remains possible during the review, preventing disruption to new assistance access for providers already under review.
• The statute requires compliance with federal timing standards for claims processing.

Terminology and concepts to watch

• Prepayment review
• Medical Assistance (MA) claims
• Fee-for-service claims
• High-risk designation
• Provider type
• Covered service
• Centers for Medicare and Medicaid Services (CMS)
• Indian Health Service (IHS) exemption
• 42 CFR 447.45 (timely processing of claims)
• Sanctions (as defined in section 256B.064)
• Minnesota Statutes 256B (specifically 256B.04, subdivision 21, paragraph j)
• Notice and reporting requirements

Relevant Terms

• prepayment review
• medical assistance claims
• fee-for-service
• high-risk designation
• provider type
• covered service
• CMS (Centers for Medicare and Medicaid Services)
• Indian Health Service
• 42 CFR 447.45
• sanctions
• 256B.064
• 256B.04 subdivision 21 paragraph j
• Minnesota Statutes chapter 256B

Relevant Terms - prepayment review - medical assistance claims - fee-for-service - high-risk designation - provider type - covered service - CMS - Indian Health Service - 42 CFR 447.45 - sanctions - 256B.064 - 256B.04 subdivision 21 paragraph j - Minnesota Statutes 256B