Specifications include, but are not limited to: provide medical review and authorization services for the Minnesota Health Care Programs; Dental – Ryan White program [1] 159 90 109 Dental – MHCP 8473 5607 6300 Prosthetics, Orthotics, Equipment, and Medical Supplies [2] 9282 8574 8935 Inpatient hospital 2013 2238 1683 Medical 12477 11539 10954 Adult (age 21 and older) mental health 1456 1599 1409 Children’s (under age 21) mental health 3111 2471 2221 Substance Use Disorder treatment [3] 0 0 0 EIDBI Comprehensive Multi-Disciplinary Evaluations (CMDEs)[4] 611 1128 2137 EIDBI Individual Treatment Plans (ITPs) [4] 1011 1837 3557 Home care [5] 4571 4296 3735 Home Care Temporary Starts [6] 909 801 645 Administrative denials [7] 7701 6901 6461 Out of State Medical Care [8] <100 <100 <100 [1] Some dental services requiring authorization are covered by the State’s Ryan White program. Those services are funded separately from other MHCP services, may include different services, and may have different authorization requirements than MHCP dental services. Generally, these authorizations are more complex than typical MHCP dental authorizations. [2] Prosthetic, orthotics, equipment, and supply authorizations may have several lines which require separate review. For example, prosthetic limbs and power wheelchairs are generally made of a base item with multiple accessories. Equipment and supplies may be medical in nature (bone growth stimulators) or rehabilitative in nature (wheelchairs). [3] Substance Use Disorder treatment has previously been approved by the local county or tribal agencies that approve eligibility. The State estimates there will be approximately 250 – 300 cases per month, or 3,000 – 3,600 cases per year. [4] Early Intensive Developmental and Behavioral Intervention (EIDBI) services are available to people under the age of 21 with autism spectrum disorder (ASD) and related conditions. Authorization of EIDBI services requires review of both a CMDE and an ITP, which are typically separately received and reviewed. This benefit became available in early 2016, and utilization has been rapidly increasing. [5] Home care authorizations may be administratively challenging due to limits on combinations of services, different providers involved in the care of the individual, and the STATE’s MMIS system. [6] Home care temporary starts require limited medical review of concise treatment notes. [7] Administrative denials are those that are submitted to the medical review agent that are not reviewed for medical necessity. Reasons for administrative denial include: The provider is not enrolled as an MHCP provider The recipient is not enrolled in MHCP The service is not covered by MHCP or the recipient’s MHCP program The service does not require authorization The request is a duplicate The recipient is in managed care Supporting documentation is missing or pages are obviously missing or illegible The authorization request was otherwise incorrectly submitted. [8] Exact number of cases of Out of State care not available.