Minnesota health care programs 2026

1. Click ‘Get Form’ to open the Minnesota Health Care Programs (MHCP) Emergency Medical Assistance Care Plan Certification Request in the editor.
2. Begin by entering the Assigned Authorization Number from MN–ITS if applicable, followed by the Requested Start Date for the care plan.
3. Complete the Member Information section thoroughly, including last name, first name, address, MHCP member ID number, date of birth, and phone number.
4. Fill out the Provider Information section with your details such as provider name, NPI, address, and contact information.
5. If applicable, provide Guardian or Responsible Party Information. Ensure all fields are filled accurately.
6. In the Emergency Medical Diagnosis Information section, include relevant ICD Diagnosis Codes and descriptions along with hospitalization dates.
7. Detail the Plan of Care by describing how discontinuation of treatment could jeopardize the member's health. Include specific treatment services or medications.
8. Check all required medical documentation boxes to ensure completeness before submission. Incomplete forms may lead to denial.
9. Finally, review all entries for accuracy and completeness before submitting your form via fax to ensure a smooth processing experience.

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