7. Adjustments
7.01System Problems
Report MAXIS systems problems to
 MAXIS Help Desk 651-296-7987
 Toll Free 1-800/383-7987
 MAXIS E-mail (PF11)
Report MMIS systems problems to:
 MMIS Help Desk 651-431-3930
 Toll Free 1-800-366-7894
7.02 Adjustment Process
Adjustment requests may be submitted to DHS for enrollees who are incorrectly enrolled in or disenrolled from MCOs due to
systems problems. Report errors specific to MCO enrollment/payment to your DHS Enrollment Coordinator.
MCO coverage may need to be adjusted outside the first year MCO change or open enrollment periods. Adjustment requests can
be filed by county staff, the state ombudsman, MCOs or MinnesotaCare enrollment reps and sent to the DHS Enrollment
Coordinators for processing. Adjustments are reviewed by DHS staff before a decision is made. In some instances, looking up
information on the system is sufficient. In other cases, calling the MCOs involved, the workers, if needed, and in other instances,
contacting the recipients themselves may be necessary to make the most appropriate decision. Much of this can be completed
and resolved at the county level, as the county is the first point of contact. Counties need to notify the affected MCO(s) of
adjustments as soon as possible, either by phone or in writing.
County staff may send Adjustment Requests on MAXIS E-Mail to e-mail address: MADJ
MinnesotaCare staff may send newborn adjustments on MS-Outlook to e-mail address: DHS HPEN/MADJ
In certain instances DHS staff will notify the worker that coding must be corrected. This coding must be corrected before an
adjustment can be made. If coding is not corrected, the adjustment will be denied, possibly resulting in reduced or no service to
the recipients and possible billing problems.
A request is not a guarantee of adjustment.
Adjustment requests will be reviewed by DHS staff.
An adjustment is usually denied or delayed if:
Coding is incorrect (counties will be notified to correct coding if appropriate).
The request is for an unreasonable length of time or not timely
Not enough information (explanation) given.
The adjustment was not requested within one year after payment was received or should have been received by the MCO.
Please include the following when requesting an adjustment:
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Case name and case number
Enrollee name
PMI number
Date/s for which adjustment is being requested (month/year)
Pay or Recover from MCO
Name of the MCO to/from which payment/recovery should be made. Include the MCO contract number if possible
For inpatient stays, include the date of admission into the hospital and the date of discharge from the hospital
Briefly, but concisely, explain the reason for the request
If an adjustment is approved and processed as requested, the payment or recovery claim on the remittance will be the sole
notification from the State to the MCO. If an adjustment request has been modified or denied, the State will respond to the person
submitting the request via the same format the request was received. i.e. to the county via email, to the MCO via fax.
Counties should use the following format for adjustment requests through MAXIS/MAIL using the e-mail code “MADJ”.
ADJUSTMENT TYPE (CHECK ONE): __NEWBORN __INPATIENT __OTHER
CLIENT(S):
PMI NUMBER(S):
NEWBORN’S DOB:
PAY: HEALTH PLAN: MONTH(S)/YEAR:
RECOVER: HEALTH PLAN: MONTH(S)/YEAR:
HMO CONTACTED (Y/N): CONTACT NAME:
* MOM’S FULL NAME/PMI:
MOM’S HEALTH PLAN (DURING BIRTH MONTH):
REASON FOR REQUEST:
COUNTY:
MinnesotaCare may submit adjustments by e-mail to DHS HPEN-MADJ with “Newborn Adjustment” in the subject line.
7.03 Adjustments
Adjustment Types
Due to continuity of care issues there may be situations that do not fit any of the policy examples listed below. If you have a case
that does not fit the policy example or you think is different, please contact your DHS Enrollment Coordinator to discuss the case.
Basis of Eligibility/Change in Major Program
When there is a change in major program or eligibility type which affects managed care, the worker will enter the managed care
change on MMIS effective the next available month. For MinnesotaCare enrollees who become pregnant, the major program
change would be effective, on RELG, retroactively to the confirmed date of conception. The MCO is only responsible to cover the
benefit set they received a capitation payment for. That benefit set is reflected by the product id on RPPH. Services covered by
the increased benefit set should be submitted to DHS on a fee-for-service basis. There will not be adjustments in these situations.
PMAP/PGAMC Example 1
The enrollee is on GAMC and in a MCO for January, February, and March. In March before the managed care enrollment cut-off
the enrollee is certified disabled and determined eligible for MA retroactive to January 1. The worker would change the major
program and basis of eligibility on RELG effective 1/1, disenroll the enrollee from the PGAMC contract effective 3/31 and enter an
exclusion span on RPPH effective 4/1. The MCO will remain responsible for all GAMC covered services for January through
March. If the enrollee receives MA services not covered under GAMC during this period, the provider rendering the MA services
should bill DHS directly as fee-for-service.
MinnesotaCare Example 1
The prepaid MinnesotaCare enrollee is active with major program “BB” eligibility for January, February and March. On March 10,
the enrollee provides documentation regarding her pregnancy. The documentation confirms the date of conception as being in
January. On RELG the rep would correctly replace the major program “BB” eligibility span with a major program “LL or KK” span
with an effective date of 1/1. A new MCO enrollment span will systematically be added to RPPH with the new product id with an
effective date of 4/1.
If the change in address involves a change in county of residence the financial worker should be sure to complete all eligibility
updates on MMIS prior to changing the case address on MAXIS. This is particularly important to avoid potential managed care
edits that would apply to the new county of residence. It is not necessary to update the RPPH screen. MMIS will re-determine
MCO availability for the new county of residence at the next capitation that follows the move. The MinnesotaCare rep will enter
the address change after the monthly billing cycle/cut-off, but before the managed care enrollment cut-off in the month before the
change is effective. There will not be adjustments in these situations.
PMAP/PGAMC Example 1
The enrollee contacts the worker 12/1 stating they are going to move to a new county on 1/1. The worker updates the address on
the system but does not transfer the case to the new county until the enrollee has moved. DO NOT update RPPH before
transferring cases on SPEC/XFER in MAXIS.
• If the client’s MCO is available in the new county, the enrollment span on RPPH remains open and there will be one continuous
span for both counties.
• When the client’s MCO is not available in the new county, the system will close the enrollment span on RPPH at the next
capitation run.
PMAP/PGAMC Example 2
The enrollee contacts their worker after managed care cut-off to report their move out of state. They request their case closed as
soon as possible. Since the capitation payment has already been issued to the MCO for next month the earliest the worker can
close MCO enrollment is the last day of the next month.
MinnesotaCare Example 1
The member moves on 1/12 to a county that does not have the member’s MCO. On 1/30 the enrollee notifies the rep that the
move has occurred. As the February capitation was issued, when the rep enters the change the system will close the RPPH span
effective 2/28 and create a new MCO span effective 3/1.
Minnesota Care Example 2
The enrollee contacts the rep 12/1 stating that they are going to move 3/1. The rep does not change the address on the system
until February. This change must be entered after the monthly billing cycle/cut-off, but before the managed care enrollment cut-off
in February. When the worker enters the change the system will determine the action needed for managed care enrollment.
Coding Error
When there is a coding error the worker or rep will enter the correction on MMIS effective the next available month. Situations will
be looked at on an individual basis to determine the need for an adjustment.
PMAP/PGAMC Example 1
On 1/5 the worker codes the enrollee into the wrong MCO effective 2/1 and the error is discovered by the enrollee on 1/8 via the
enrollment notice. The enrollee contacts the worker regarding the error on 1/8. Since the February capitation has not been paid,
the worker should delete the wrong enrollment span and enter the correct enrollment span. This is not an adjustment situation.
PMAP/PGAMC Example 2
On 1/5 the worker codes the enrollee into the wrong MCO effective 2/1 but the error is not discovered by the enrollee until after
capitation when they receive the MCO membership packet. The enrollee contacts the worker regarding the error. The worker is
unable to correct the error for February as a capitation payment has been paid. The worker should explain this to the enrollee and
determine if this will cause a problem for the enrollee. If the enrollee and the worker determine that there will not be access
problems then the worker will change the MCO effective 3/1. If the enrollee and the worker determine a continuity of care issue
exists, contact your DHS enrollment coordinator before submitting an adjustment. Exceptions are allowed as last resort.
MinnesotaCare Example 1
On 1/5 the enrollment form is scanned incorrectly and codes the enrollee into the wrong MCO effective 2/1 and the error is
discovered by the enrollee on 1/8 via the enrollment notice. The enrollee contacts MinnesotaCare regarding the error on 1/8.
MinnesotaCare will notify the managed care enrollment coordinator to delete the wrong enrollment span and enter the correct
enrollment span, since the February capitation payment has not been paid. This is not an adjustment situation.
MinnesotaCare Example 2
On 1/5 the enrollment form is scanned incorrectly and codes the enrollee into the wrong MCO effective 2/1 but the error is not
discovered by the enrollee until after capitation when they receive the MCO membership packet. The enrollee contacts
MinnesotaCare regarding the error. The MCO enrollment cannot be corrected for February, as a capitation payment has been
paid. MinnesotaCare should explain this to the enrollee and determine if this will cause a problem for the enrollee. If it is
determined that there will not be access problems then MinnesotaCare will notify the managed care enrollment coordinator to
change the MCO effective 3/1. If a determination is made that a continuity of care issue exists, an adjustment must be requested
to possibly give the enrollee FFS that month. The MCO needs to be notified of the situation and the reason for an adjustment.
When there is a phone-in coding (enrollment error) for Prepaid MinnesotaCare, MinnesotaCare will notify the enrollment
coordinator to enter the correction on MMIS.
Death
Capitation payments issued for any month(s) after the month of death when medical eligibility is terminated due to death, are
recovered. Adjustments in this instance do not need to be requested through MAXIS e-mail MADJ. These recoveries are identified
monthly through an MMIS report. DHS identifies and recovers any capitation claims after the date of death.
Enrollment Form Error
When there is an enrollment form error (i.e., client error), the client must complete a new enrollment form. After a new enrollment
form is received, the county worker or managed care enrollment coordinator will enter the correction on MMIS effective the next
available month. There will not be adjustments in these situations. (For any system related problems associated with system
maintained enrollment form information contact your DHS Enrollment Coordinator).
Incarceration
An MA recipient who is incarcerated loses MA eligibility. (For policy see Health Care Manual 0906.09.01) When the worker fails to
close MA eligibility and if at initial enrollment the enrollee is incorrectly enrolled into PMAP, the enrollee should be coded out of the
MCO when the mistake is discovered and an adjustment should be requested to recover capitations paid to the MCO erroneously.
If the enrollee has been enrolled in PMAP ongoing, the enrollee must be disenrolled from the MCO the first of the next available
month. There will not be adjustments in these situations. PGAMC enrollees who are incarcerated and continue to meet eligibility
requirements do not lose GAMC eligibility and should not be disenrolled from the MCO. See 9.10 Service for Incarcerated
Persons. There will not be adjustments in these situations. A MinnesotaCare enrollee who is incarcerated loses their
MinnesotaCare eligibility at the time of their renewal of eligibility. (For policy see Health Care Manual 0906.09) A MinnesotaCare
applicant residing in a correctional or detention facility is not eligible for MinnesotaCare. See 9.10 Service for Incarcerated
Persons. There will not be adjustments in these situations.
Inpatient Adjustments
All MA/GAMC MCO contracts specify that when termination takes place due to ineligibility for MA or GAMC or for participation in
the prepaid MA or GAMC program and the enrollee is hospitalized in an acute care facility on the effective date of ineligibility,
MCO coverage will cease on the first day following discharge from the hospital. The State will not pay to the MCO a capitation
payment for any month after the month in which the enrollee’s eligibility for MA or GAMC, MinnesotaCare, prepaid MA or prepaid
GAMC was terminated. Actual dates for admission and discharge must be part of all documentation.
1. Inpatient at Time of Enrollment, PMAP/PGAMC
MCO coverage of clients who are hospitalized in an acute care facility at the time coverage otherwise would become effective
shall commence the first of the month following the month of discharge from the hospital. An adjustment should be requested to
recover the capitation paid to the MCO.
Example
The enrollee is enrolled into the MCO for 2/1. On 1/28 the enrollee is hospitalized. On 2/5 the enrollee is discharged from the
hospital. The capitation payment for February would need to be recovered. The worker or the MCO should send an adjustment
request.
2. Inpatient at Time of Enrollment, MinnesotaCare
MCO coverage of MinnesotaCare enrollees who are hospitalized in an acute care facility at the time coverage otherwise would
become effective shall commence upon discharge from the hospital. MN Statute 256L.05 subd.3. An adjustment is not necessary
in these situations.
Example
The enrollee is enrolled into the MCO for 2/1. On 1/28 the member is hospitalized. On 2/5 the enrollee is discharged from the
hospital. The capitation payment for February would not be recovered. MCO coverage begins at midnight on the day after
discharge from the hospital. The MCO is not responsible for any hospital related claims through the date of discharge.
3. Inpatient at Time of Enrollment, MSHO Enrollee
MSHO enrollees who are hospitalized in an acute care facility on the first effective date of coverage will remain in the MCO.
Hospital costs for the stay begun before enrollment shall not be the responsibility of the MCO. An adjustment is not necessary in
these situations.
Example
The enrollee is enrolled into MSHO for 2/1. On 1/28 the enrollee is hospitalized. On 2/5 the enrollee is discharged from the
hospital. The capitation payment for February would not be recovered. MSHO coverage would begin 2/1. The MCO is not
responsible for any hospital related claims through the date of discharge. An adjustment is not necessary in these situations.
4. Inpatient at Time of MCO Change
PMHCP enrollee’s who are hospitalized in an acute care facility on the effective date of their enrollment into a different MCO, ex.
first year change, open enrollment, etc. will not be allowed to change MCOs until the month following their discharge. The MCO in
effect at the time of hospital admission is responsible for the enrollee’s benefit set through the end of the month of discharge. An
adjustment should be requested to recover the capitation paid to the new MCO along with a request to pay the old MCO.
5. Inpatient at Time of Enrollment, MNDHO
MCO coverage of clients who are hospitalized in an acute care facility or a neurobehavioral rehabilitative hospital at the time
coverage otherwise would become effective shall commence the first of the month following the month of discharge from the
hospital. An adjustment should be requested to recover the capitation paid to the MCO.
Example
The enrollee is enrolled into the MCO for 2/1. On 1/28 the enrollee is hospitalized. On 2/5 the enrollee is discharged from the
hospital. The capitation payment for February would need to be recovered. The worker or the MCO should send an adjustment
request.
Placements in State Institutions
For recipients who are in a state institution, including Regional Treatment Centers (RTC), Institutions for Mental Disease (IMD),
and state-operated long term care facilities at the time of initial enrollment in the MCO, the effective date of enrollment will be
delayed until the month following the enrollee’s discharge from the facility. Prior to requesting the adjustment, the county financial
worker should end MCO enrollment and enter “ZZ” exclusion for the next available month. An adjustment should be requested to
recover the capitation paid to the MCO. If the MCO places an enrollee in a state institution, for acute care services, or the enrollee
is placed by court order the enrollee will remain enrolled in the MCO. If, via the placement, the enrollee is placed in an RTC bed
licensed as an inpatient bed MinnesotaCare inpatient co-pays and limitations will apply to the applicable MinnesotaCare benefit
sets.
Example
The enrollee is initially enrolled into the MCO for October 1. On 9/27 the enrollee enters a Regional Treatment Center (RTC). The
county financial worker should end MCO enrollment effective 10/31 and enter “ZZ” exclusion effective 11/1. The county financial
worker or MCO should request an adjustment to recover the October capitation.
Newborn
For newborns born on or after 10/1/04, to a mother covered by a MCO for the month of birth, by contract DHS guarantees
retroactive payment to the same MCO for an eligible newborn for the birth month, unless the newborn meets an exclusion reason
(see 2.04.01 PMAP/PGAMC Excluded Populations). If the newborn is enrolled into the MCO on MMIS within 90 days of birth, the
MCO will be paid retroactively for the birth month and all succeeding months unless a MCO change is requested. Submit an
adjustment request via MAXIS/MAIL to MADJ to pay the MCO for the appropriate month(s). If the newborn is not added to the
case within 90 days, the county should enroll the newborn for the next available month and request a payment adjustment to pay
the MCO for the birth month only.
Payment Application Error
If the MinnesotaCare premium payment is applied to the wrong obligation it may result in either a delay in enrollment or a non
payment cancellation. If this happens and the enrollee is given retroactive MinnesotaCare eligibility, the enrollee will have fee-forservice coverage.
Reinstatement
An enrollee whose termination from the MCO has been entered into MMIS by the monthly managed care enrollment cut-off date
may be reinstated for that month with no lapse in coverage, if medical eligibility is reestablished and entered into MMIS on or
before the last working day of the month. This will result in an appropriate retroactive capitation payment. No adjustment should
be requested in this situation.
System Error
If the system prevents or inaccurately enrolls a client into managed care, contact your DHS Enrollment Coordinator.
TPL
For enrollees who have private prepaid health care coverage through an MCO, the MCO must coordinate benefits in accordance
with MN Rules Part 9505.0070 and Minnesota Statute section 62A.046. There will be no adjustments in these situations.