Forms, Templates and Applications
HMO Annual Report Forms
Beginning April 2014, Provider Network data must be submitted to the Central Data Repository hosted by the Minnesota Department of Human Services using a fixed length text file format as specified in the Provider Network File Layout. This provider network data file will satisfy the annual report requirements under Minnesota Rules 4685.2100 (D) and provider termination reporting requirements under Minnesota Statutes 62D.08, subd. 5. The fixed length provider network data file format and the Provider Network File Layout instructions replace the “Participating Provider Network Listing 4a” and the “Data Dictionary Participating Network Provider Listing 4b.” Please see the “State of Minnesota - Provider Network File Layout” document and Administrative Bulletin #2014-1 listed below.
- Enrollment (Excel: 38KB)
- Statement of Revenue, Expenses and Net Income (Excel: 28KB)
- Reallocation of Expenses and Investment Income (Excel: 18KB)
- State of Minnesota – Provider Network File Layout (Excel: 143KB)
- Administrative Bulletin #2014-1 (PDF: 28KB/2 pages)
The Minnesota Legislature repealed the following forms: #2 Summary of Complaints and Grievances; #3 Summary of Chemical Dependency Claims; #5 Medical Necessity Report.
Please send an email to firstname.lastname@example.org if you have any questions regarding HMO annual reports, provider termination reporting, or the submission of HMO and provider network data and information.