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Tennessen Warning Hide Section

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

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Information About You

Your Role

If MCO, what plan?

State Agency

If DHS - what admin/area

County

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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 - choose most applicable
Child Care Assistance Healthcare Benefits (including Medical Assistance) Minnesota Care Other Public Benefits (SNAP/Food Stamps/Cash Assistance/Electronic Benefit Transfer (EBT)) Removal from exclusion list request

Specific Program, if known

Who are you reporting?
Medicaid provider or childcare provider A person receiving DHS benefits or services (for example: SNAP, CCAP, or Medical Assistance)

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 Date of Birth

Recipient Address

Recicpent City

Recipient State

Recipient Zip Code

Record Information Hide Section

From Name*

Subject*

Program Text

From Address*

Complaint received via

Status