Advance Recipient Notice of Non-covered Service/Item Instructions
MHCP does not cover:
Health services
• When a physician’s order is required but not obtained
• Not in the recipient’s plan of care, individual treatment, education or service plan
• That are of a lower quality standard than the prevailing community standard of the provider’s professional peers (providers of
services that are determined to be of low quality must bear the cost of these services)
• Other than emergency health services, provided without the full knowledge and consent of the recipient or the recipient’s legal
guardian
• Provided outside the United States or by providers whose financial institutions or entities are located outside the U.S.
• Provided by practitioners working outside their scope of practice or without appropriate credentials
Missed appointments (do not bill MHCP recipients for missed appointments)
Reversal of voluntary sterilizations
Primarily for cosmetic purposes
Vocational or educational services, including functional evaluations or employment physicals, except as provided under individual
education plan-related services
Upgrade An upgrade is not a separate part of a service/item; a service/item that is an increased, newer or more advanced
version of its base. For example, a power wheel chair is an upgrade of a manual wheel chair, or a CT scan is an
upgrade of an x-ray.
Add-on An add-on is a separate part of a service/item; a service/item that is added to enhance a service/item. For example, a
basket is an add-on to a walker, or an ultrasound modality is an add-on to a therapy.
Provider
Accept payment from a recipient for a non-covered service/item only when all of the following apply:
• The recipient is not enrolled in the restricted recipient program OR the recipient is enrolled in the restricted recipient program and
the provider is not one of the provider types designated for the recipient’s health care services
• You reviewed with the recipient the service limits, reason(s) the service/item is not covered and available covered alternatives
• You obtain a recipient signature on this form
You must request authorization/seek payment from the other insurance or Medicare before you request authorization/payment from
MHCP or the recipient
When a service/item requires authorization, request authorization through the MHCP medical review agent. If the authorization is
denied for other than a billing error or lack of documentation, you may bill the recipient
Do not request payment from the recipient for:
• A service that requires authorization unless authorization was denied as not medically necessary and you have reviewed all other
therapeutic alternatives with the recipient
• A service MHCP denied for reasons related to billing requirements
• Standard shipping or delivery and setup of medical equipment or medical supplies
• Services included in the recipient’s long term care per diem
• More than your usual and customary charge for the service/item
• The difference between what MHCP would pay for a less costly alternative service and the upgraded service provided
If MHCP makes any payment, you may bill the recipient only for amounts designated as cost-sharing or spenddown
Do not use this form for controlled substance prescriptions, gabapentin or tramadol (see MHCP Advance Recipient Notice of Non-
covered Prescription (DHS-3641)
Recipient
You are asking for a service or item that MHCP does not cover or you do not meet the criteria for it. Your health care provider has to tell
you why the service or item is not covered. The provider also has to tell you about other services or items that MHCP covers. If you still
want the non-covered service or item, sign the form. You are responsible to pay the provider for the service or item.
If you have questions about this form, call the MHCP Member Help Desk 651-431-2670 or 1-800- 657-3739.
If you believe your service or item should have been covered by MHCP and you were billed by the provider in error, you have the right
to appeal.
