Managed Care Section

Forms, Templates and Applications

Consumer Forms

HMO Annual Report Forms

The Minnesota Legislature repealed the following forms: #2 Summary of Complaints and Grievances; #3 Summary of Chemical Dependency Claims; #5 Medical Necessity Report. Form #4 Provider Network submission has been revised. Please be sure to use the revised Form 4a. A Data Dictionary Form 4b has been provided and must be used with Form 4a. Form 4a will satisfy the provider network filing requirement for both MDH and DHS.

Enrollment (Excel: 41kb)
Participating Provider Network Listing 4a (Excel)
Data Dictionary Participating Network Provider Listing 4b (Word)
Statement of Revenue, Expenses and Net Income (Excel: 47kb)
Reallocation of Expenses and Investment Income (Excel: 47kb)

HMO Rate Filing Form

HMO Transmittal Form

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For questions about this page, please contact the Minnesota Department of Health's Compliance Monitoring Division, Managed Care Section: health.mcs@state.mn.us

See also > Compliance Monitoring Division Home Page

Updated January 2, 2013Wednesday, 02-Jan-2013 13:55:01 CST