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Request a Denial, Termination or Reduction (DTR)

For Medica Care Coordinators

If you have issues when completing this form, please reach out to the Clinical Liaisons via email at [email protected].

Fields marked with an asterisk * are required.

Enter the date you notified the member of a denial, termination or reduction of a service or item or the date the member notified you they would like to terminate or reduce a current service or item. This date is the start of the 10 day compliance clock and must be submitted for processing as soon as possible.

Care Coordinator Information

Member Information

Member product*
If member is on EW, are you closing EW?*

If closing Elderly Waiver, you are responsible for completing the process your organization follows to actively close the EW timeline in MMIS. Allowing the waiver to close naturally is not appropriate. For members who are no longer eligible for EW, and for members who have entered a nursing home for 30 days the waiver needs to be closed.

Without this, DHS does not have what they need to:

  • - Pay Medica appropriately for members on EW and those not on EW
  • - Pay nursing home providers after Medica's liability is complete (payment period where we pay for the nursing home care)

Medica is subject to financial penalties when waivers are not managed correctly.

Primary Care Provider Information

Service/Item Information

Action*

Termination

Select an option*

If Care Coordinator would like to determine the effective or start date of the DTR, submission of form must be made at least 25 calendar days prior to the desired effective date to allow for processing. If a DTR form is submitted less than 25 calendar days prior to desired effective date, Medica cannot guarantee that a requested effective date will be honored.

Reduction

Select an option*

Please ensure that you are providing a Requested new authorization end Date that is greater than the Requested authorization start date.

If Care Coordinator would like to determine the effective or start date of the DTR, submission of form must be made at least 25 calendar days prior to the desired effective date to allow for processing. If a DTR form is submitted less than 25 calendar days prior to desired effective date, Medica cannot guarantee that a requested effective date will be honored.

Initiated/requested by*

Provide rationale/reason to support the DTR to include how the member's needs will be met with the reduction or termination or if it no longer an assessed need. In addition:

  • - PCA/CFSS DTR – Indicate what has changed from the previous assessment resulting in a reduction or termination. Must attach assessment documents; PCA Legacy Assessment or MnCHOICES documents including the Supplemental Summary Charts and Assessment Summary. Please include the previous PCA/CFSS assessment if available.
  • - Customized Living - include current daily rate and reduced daily rate
  • - Do not reference Benefit Guidelines
Add a second service/item?
Action*

Termination

Select an option*

If Care Coordinator would like to determine the effective or start date of the DTR, submission of form must be made at least 25 calendar days prior to the desired effective date to allow for processing. If a DTR form is submitted less than 25 calendar days prior to desired effective date, Medica cannot guarantee that a requested effective date will be honored..

Select an option*

Please ensure that you are providing a Requested new authorization end Date that is greater than the Requested authorization start date.

If Care Coordinator would like to determine the effective or start date of the DTR, submission of form must be made at least 25 calendar days prior to the desired effective date to allow for processing. If a DTR form is submitted less than 25 calendar days prior to desired effective date, Medica cannot guarantee that a requested effective date will be honored.

Initiated/requested by*

Provide rationale/reason to support the DTR to include how the member's needs will be met with the reduction or termination or if it no longer an assessed need. In addition:

  • - PCA/CFSS DTR – Indicate what has changed from the previous assessment resulting in a reduction or termination. Must attach assessment documents; PCA Legacy Assessment or MnCHOICES documents including the Supplemental Summary Charts and Assessment Summary. Please include the previous PCA/CFSS assessment if available.
  • - Customized Living - include current daily rate and reduced daily rate
  • - Do not reference Benefit Guidelines
Add a third service/item?
Action*

Termination

Select an option*

If Care Coordinator would like to determine the effective or start date of the DTR, submission of form must be made at least 25 calendar days prior to the desired effective date to allow for processing. If a DTR form is submitted less than 25 calendar days prior to desired effective date, Medica cannot guarantee that a requested effective date will be honored.

Reduction

Select an option*

Please ensure that you are providing a Requested new authorization end Date that is greater than the Requested authorization start date.

If Care Coordinator would like to determine the effective or start date of the DTR, submission of form must be made at least 25 calendar days prior to the desired effective date to allow for processing. If a DTR form is submitted less than 25 calendar days prior to desired effective date, Medica cannot guarantee that a requested effective date will be honored.

Initiated/requested by*

Provide rationale/reason to support the DTR to include how the member's needs will be met with the reduction or termination or if it no longer an assessed need. In addition:

  • - PCA/CFSS DTR – Indicate what has changed from the previous assessment resulting in a reduction or termination. Must attach assessment documents; PCA Legacy Assessment or MnCHOICES documents including the Supplemental Summary Charts and Assessment Summary. Please include the previous PCA/CFSS assessment if available.
  • - Customized Living - include current daily rate and reduced daily rate
  • - Do not reference Benefit Guidelines