Denial-Termination-Reduction (DTR) Request Form

* DTR Letter Must be Mailed to Patient within 14 Days of “Date Request Received” * please return to HealthPartners via email at: hp_mshomsc_cc@HealthPartners.Com within 72 hours of request, denial or reduction

CARE COORDINATOR	Care Coordinator CompleteS this Section	CARE COORDINATOR
Care Coordinator completes their section of DTR form and emails to hp_mshomsc_cc@HealthPartners.Com
DTR Action Code:	Denial	Termination	Reduction
(Choose one: Denial, Termination, or Reduction)	Service(s) not currently being received – This will always be “Prospective”	Service(s) currently being received are ended – This will always be “Concurrent”	Frequency/rate of current service(s) are being reduced – This will always be “Concurrent”
Prospective	Concurrent	Concurrent
Program/Letter Type: Chose one:
(MSHO) MSHO Integrated Denial mMSHO	MSHO DTR for Extended PCA Only
(MSC+) Medicaid DTR for MSC+	MSC+ DTR for Extended PCA Only
CC Name:	Phone:	Fax:	952-853-8744
Member Name:	DOB:	ID #:	ICD-10:	Diagnostic Code
Alternative Address: (other than that provided by DHS)
Date Request Received:	Assure CC documentation in CarePartner.
Date of Assessment - or - Date All Decision-Making Information is Obtained - or - Date Patient Calls Requesting Service Please see Work Aid if further clarification is needed.
Date of Decision:	* CC should document notification to member in CarePartner.
Date CC E-mails DTR Form to SC & Supervisors (within 8 days of Date Request Received)
SERVICE REQUESTED:	REQUESTED UNITS:	per
SERVICE CODE: (HCPC Code)	APPROVED UNITS:	per
TYPE OF UNITS: (See S&I for Options) (ex., 15 min. unit = 1 unit or 1 can = 1 unit)	DENIED UNITS: (ex., CLS or LifeLine is monthly and ADC is weekly)	per
REASON for DTR: (Please check only ONE box) EW Budget Exceeded (use when keeping EW open) EW Service Reduction EW Service Termination EW Service Reduce Member Choice EW SNBC – Service Term Member Choice EW Not Covered EW Institutional	EW Eligibility (Check this option when patient does not qualify for EW or when closing EW) EW SNBC – Service Request Denied (Check this option when patient is open to EW, but new service is denied) EW NF LOC Not Met (requires 30 day notice) EW Nursing Home NF LOC Not Met (requires 30 day notice) PMAP Initial (PCA/EW request) PMAP Reassess (PCA/EW request) PMAP Mbr Refused Reassess (PCA/EW request)
Check if No Known Provider	Provider Billing Name:
Care Coordinator completes their section of DTR form and emails to hp_mshomsc_cc@HealthPartners.Com

SERVICE COORDINATOR	SERVICE COORDINATOR COMPLETES THIS SECTION	SERVICE COORDINATOR
Service Coordinator completes this section, emails DTR form to the Supervisors.
Provider Name:	Provider Tax ID Number:
Provider Fax Number:	Provider Phone Number:
Notification to Provider: (by telephone – Please verify their fax number)	Date:	Time:
Inform provider that DTR will be faxed to them with specific dates pertaining to the Denial, Termination or Reduction of the service indicated above.
Effective Date of DTR: If “Prospective” Same as “Date of Decision” If “Concurrent” 21 Calendar Days after Date of Decision	Service Request End Date: 4 weeks after Effective Date of DTR if weekly service, otherwise one month for monthly service.	Units During 30 Days If weekly units, multiply by 4 If monthly units, multiply by 1
Total Requested Units:
Total Certified Units: (Approved Units)
Service Code Category (Please check one) 2151 – EW – Adult Day Care Services 2126 – EW – Homemaker 2149 – EW – Non-Medical Transportation 2150 – EW – Eligibility (use when “EW Eligibility” is checked under “REASON for DTR”) 2152 – EW – 24-Hour Customized Living 2104 – EW – Adult Day Service Bath 2112 – EW – Chore Services 2114 – EW – Companion Services 2115 – EW – CDCS 2118 – EW – Customized Living Services	2122 – EW – Corporate Foster Care Services 2123 – EW – Home Delivered Meals 2124 – EW – Extended Services HHA, PDN, PCA 2132 – EW – Environment Accessibility Adaptations 2139 – EW – Respite Care 2142 – EW – Specialized Supplies and Equipment 2145 – EW – Telehomecare 2146 – EW – Caregiver Training and Education 2148 – EW – Transitional Supports 2199 – EW - Other
* * Supervisors will forward to CMTA Inbox. * *
CMTA	CMTA COMPLETES THIS SECTION	CMTA
CMTA proceeds with mailing letter to Patient and faxing to Provider.
Date DTR Letter Faxed to Provider:	Name of CMTA Faxing to Provider:	Auth #:
CMTA brings copies of completed DTR documents to Supervisor.
SUPERVISOR	SUPERVISOR COMPLETES THIS SECTION	SUPERVISOR
Supervisor completes the Audit Questionnaire.
SUPERVISOR SIGN-OFF SIGNATURE:	DATE:
Document Handling Care Coordinator completes their section of DTR form and emails to the Service Coordinators (ServiceCoord DTR). Service Coordinator completes their section of DTR form (including calling the Provider) and emails it to the Supervisors. Service Coordinators will fill in the end date on the S&I as applicable. Supervisor verifies the information and forwards it to the CMTA Inbox. CMTA creates DTR in CarePartner, completes a verification check, and faxes the letter to the Provider. CMTA brings copies of completed DTR documents to Supervisor. Supervisor completes the Audit Questionnaire and notifies the CMTA that it is complete so the CMTA can close the authorization. Supervisor reviews Quarterly Report of DTR Audit Questionnaires.