Tennessen Warning

By making a complaint, you are providing DHS with information to help us determine whether financial fraud or abuse has occurred, and if it has, whether an individual or provider is responsible. It may also help DHS determine whether any violations of Minnesota statutes or rules have occurred. You have privacy rights under the Minnesota Government Data Practices Act. This law protects your privacy, but also lets DHS give the information you provide to others if it is required or allowed by law. You are not required to provide DHS with this information. The information you provide may be used in legal or administrative action. If you choose NOT to provide the information, DHS may not be able to fully investigate the compliant you are filing. During an investigation all information DHS collects is confidential until the investigation is completed. DHS is not able to provide you with an update on the status of your report during the investigation. When the investigation is complete, some information may become public or private or it may remain confidential. The information you provide may be shared with individuals who work or volunteer with DHS or other state, county, local, federal or private agencies authorized by law. DHS may also share information with the Minnesota Department of Education, court officials, county attorneys, the attorney general, or other law enforcement or fraud investigators. If you have questions regarding an Explanation of Medical Benefits (EOMB) you have received, please contact the member help desk at 651-431-2670 or 800-657-3739. Medical Assistance Provider Fraud – Medical Assistance provider fraud relates to fraud in Minnesota’s Medicaid system by providers. There are over 100 provider types. Some examples of providers include: doctors, personal care assistants and transportation companies. Examples of fraud include: false and/or fraudulent claims, billing for health care services that weren’t provided, or reporting false employment hours or time sheets. For suspected fraud involving health care providers, please fill out this form or call 651-431-2650, or 800-657-3750. Please check to acknowledge that you have read and understood the Tennessen Warning above

Tips

Information About You Your Role Public/Community Member County Employee Provider State Employee Managed Care Organization (MCO) If MCO, what plan? Blue Plus Health Partners Hennepin Health Itasca Medical Care Medica Prime West South Country UCare United Health Care State Agency Department of Human Services (DHS) Department of Health (MDH) Department of Human Services (DHS) - Licensing If DHS - what admin/area County 01 - Aitkin 02 - Anoka 03 - Becker 04 - Beltrami 05 - Benton 06 - Big Stone 07 - Blue Earth 08 - Brown 09 - Carlton 10 - Carver 11 - Cass 12 - Chippewa 13 - Chisago 14 - Clay 15 - Clearwater 16 - Cook 17 - Cottonwood 18 - Crow Wing 19 - Dakota 20 - Dodge 21 - Douglas 22 - Faribault 23 - Fillmore 24 - Freeborn 25 - Goodhue 26 - Grant 27 - Hennepin 28 - Houston 29 - Hubbard 30 - Isanti 31 - Itasca 32 - Jackson 33 - Kanabec 34 - Kandiyohi 35 - Kittson 36 - Koochiching 37 - Lac Qui Parle 38 - Lake 39 - Lake of the Woods 40 - Le Sueur 41 - Lincoln 42 - Lyon 43 - McLeod 44 - Mahnomen 45 - Marshall 46 - Martin 47 - Meeker 48 - Mille Lacs 49 - Morrison 50 - Mower 51 - Murray 52 - Nicollet 53 - Nobles 54 - Norman 55 - Olmsted 56 - Otter Tail 57 - Pennington 58 - Pine 59 - Pipestone 60 - Polk 61 - Pope 62 - Ramsey 63 - Red Lake 64 - Redwood 65 - Renville 66 - Rice 67 - Rock 68 - Roseau 69 - Saint Louis 70 - Scott 71 - Sherburne 72 - Sibley 73 - Stearns 74 - Steele 75 - Stevens 76 - Swift 77 - Todd 78 - Traverse 79 - Wabasha 80 - Wadena 81 - Waseca 82 - Washington 83 - Watonwan 84 - Wilkin 85 - Winona 86 - Wright 87 - Yellow Medicine 89 - Out of State 95 - DHS - MA 99 - Canada Please Read If you provide your information, it would allow us to reach out and ask questions to better understand your concern. We understand that you may not be able to provide all the information requested below. To assist us in reviewing your concern, please provide as much information as possible. Your First Name Your Last Name Your Email Your Phone Number Applicable documentation: If you need to add more files/attachments, please complete the form and follow the instructions on the next page. Information About Your Concern Program Child Care Assistance Healthcare Benefits (including Medical Assistance) Minnesota Care Unknown Other Public Benefits (SNAP/Food Stamps/Cash Assistance/Electronic Benefit Transfer (EBT)) Specific Program, if known Who are you reporting? Provider Recipient Unknown What is your concern? When did the activity occur? If you do not know exact dates, please give an approximate. Has this concern been filed anywhere else? Yes No If yes, with whom has this concern been filed? Information About Who is Involved in Your Concern Provider Name Provider Number Provider Address License Number Additional Providers/Provider information Recipient First Name Recipient Last Name Recipient ID Recipient Address Recipient Date of Birth

Record Information

From Name* Subject* Program Text From Address* Complaint received via DHS SharePoint Webform Fax Hotline In Person Mail (US/Fed Ex/UPS etc) Non-SIRS Email Not Applicable OIG Web Report SIRS Email Telephone (Non-Hotline) Status New Open Pending Resolved Closed Reopen Merged