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The health services in items A to X are not eligible for payment under medical assistance:


health service paid for directly by a recipient or other source unless the recipient's eligibility is retroactive and the provider bills the medical assistance program for the purpose of repaying the recipient according to part 9505.0450, subpart 3;


drugs which are not in the drug formulary or which have not received prior authorization;


a health service for which the required prior authorization was not obtained, or, except in the case of an emergency, a health service provided before the date of approval of the prior authorization request;




missed or canceled appointments;


telephone calls or other communications that were not face-to-face between the provider and the recipient unless authorized by parts 9505.0170 to 9505.0475;


reports required solely for insurance or legal purposes unless requested by the local agency or department;


an aversive procedure, including cash penalties from recipients, unless otherwise provided by state rules;


a health service that does not comply with parts 9505.0170 to 9505.0475;


separate charges for the preparation of bills;


separate charges for mileage for purposes other than medical transportation of a recipient;


a health service that is not provided directly to the recipient, unless the service is a covered service;


concurrent care by more than one provider of the same type of provider or health service specialty, for the same diagnosis, without an appropriate medical referral detailing the medical necessity of the concurrent care, if the provider has reason to know concurrent care is being provided. In this event, the department shall pay the first submitted claim;


a health service, other than an emergency health service, provided to a recipient without the knowledge and consent of the recipient or the recipient's legal guardian, or a health service provided without a physician's order when the order is required by parts 9505.0170 to 9505.0475, or a health service that is not in the recipient's plan of care;


a health service that is not documented in the recipient's health care record or medical record as required in part 9505.1800, subpart 1;


a health service other than an emergency health service provided to a recipient in a long-term care facility and which is not in the recipient's plan of care or which has not been ordered, in writing, by a physician when an order is required;


an abortion that does not comply with Code of Federal Regulations, title 42, sections 441.200 to 441.208 or Minnesota Statutes, sections 256B.02, subdivision 8 and 256B.0625;


a health service that is of a lower standard of quality than the prevailing community standard of the provider's professional peers. In this event, the provider of service of a lower standard of quality is responsible for bearing the cost of the service;


a health service that is only for a vocational purpose or an educational purpose that is not related to a health service;


except for an emergency, more than one consultation by a provider per recipient per day; for purposes of this item, "consultation" means a meeting of two or more physicians to evaluate the nature and progress of disease in a recipient and to establish the diagnosis, prognosis, and therapy;


except for an emergency, or as allowed in item V, more than one office, hospital, long-term care facility, or home visit by the same provider per recipient per day;


more than one home visit for a particular type of home health service by a home health agency per recipient per day except as specified in the recipient's plan of care;


record keeping, charting, or documenting a health service related to providing a covered service; and


services for detoxification which are not medically necessary to treat an emergency.

Statutory Authority:

MS s 256B.04


12 SR 624; L 1988 c 689 art 2 s 268

Published Electronically:

August 12, 2008

Official Publication of the State of Minnesota
Revisor of Statutes