What is the difference between a service agreement and MHCP prior authorization?

A service agreement is the lead agency's authorization for waiver, alternative care, home care, PCA, and CFSS services. The county, Tribal nation, or managed care case manager enters it in MMIS with line items for each service, provider, rate, date span, and unit total, and DHS sends the provider a service authorization letter. MHCP prior authorization covers state plan services that DHS requires be approved in advance; the provider requests it on the MHCP Authorization Form (DHS-4695) and the medical review agent, Acentra Health, decides it.

How does the authorization get onto the MHCP claim?

MMIS matches each claim line against the authorization or service agreement by member, provider, procedure code and modifiers, date of service, and units. The MN-ITS 837P claim information screen has an authorization number field, and an 837P batch carries the number in REF*G1. Whether MHCP requires the number for a given service is stated in the MN-ITS 837P user guide for that service. The MHCP Authorization Form (DHS-4695) itself asks for the same elements per service line: procedure code, up to four modifiers, diagnosis, start and end dates, units, and the rendering provider NPI or UMPI.

What happens when authorized units run out or the dates lapse?

MHCP pays only claim lines that fall inside the authorization's date span and within its remaining units for that procedure code. A line beyond those limits denies, typically with claim adjustment reason code CO-197 (authorization absent), CO-198 (authorization exceeded), or CO-119 (benefit maximum reached). Services delivered before an amendment is approved are usually unpayable, so the provider must ask the case manager to amend the service agreement, or file a change request on DHS-4695, before the units or dates are exhausted.

How long does MHCP prior authorization take?

The MHCP Provider Manual authorization chapter says the medical review agent, Acentra Health, takes initial action, meaning approve, deny, or pend for additional information, within five business days of receipt. If more information is required, the case is placed in pending status for at least 10 calendar days, and the agent takes final action within three business days after the information arrives. The review agent or MHCP sends written notice of the decision to the provider and the member. For EIDBI, Acentra reviews a CMDE or ITP within seven calendar days as of January 1, 2026.

Does an approved authorization guarantee MHCP payment?

No. An approved service agreement or MHCP prior authorization confirms that the service is authorized for that member, provider, code, date span, and unit total. Payment still depends on the member being eligible on the date of service, the provider being enrolled and affiliated, the service being delivered and documented before the claim, and the claim matching the authorization line. For PCA and CFSS, the visit must also be verified in the HHAeXchange EVV aggregator.

Service agreements and MHCP prior authorization: how they drive claims

Short answer

MHCP prior authorization and waiver service agreements are two different approvals that do the same job on a claim: they tell MMIS which member, provider, procedure code, dates, and units Minnesota Health Care Programs will pay for. A waiver, home care, or CFSS service is authorized when the lead agency case manager enters a service agreement in MMIS and a service authorization letter lands in the SAL folder of the provider's MN-ITS mailbox. A state plan service that needs prior authorization is requested on the MHCP Authorization Form (DHS-4695), with program-specific attachments, and reviewed by the medical review agent, Acentra Health. Either way, the claim is matched against the authorization, and a line outside its dates, code, or remaining units denies.

At a glance

Service agreement: Lead agency enters it in MMIS for waiver, AC, home care, and CFSS; letter arrives in the MN-ITS SAL folder
Prior authorization: MHCP Authorization Form (DHS-4695) plus program-specific forms, reviewed by Acentra Health
Review timeline: Initial action within 5 business days; pended at least 10 calendar days; final action within 3 business days after information arrives
ARMHS threshold: Authorization above 300 hours per calendar year (as of September 2026); above 200 hours from January 1, 2027
CFSS authorization: No later than 40 calendar days from the assessment (Minn. Stat. § 256B.85, subd. 8)
Common denial codes: CO-197, CO-198, CO-119 when the line is outside the authorization

Key takeaways

Waiver, alternative care, home care, and CFSS services are authorized by a lead agency service agreement entered in MMIS; the provider receives a service authorization letter in the SAL folder of the MN-ITS mailbox.
MHCP prior authorization for state plan services is requested on DHS-4695 with program-specific forms and reviewed by Acentra Health (formerly KEPRO), which takes initial action within five business days of receipt.
A service agreement or authorization specifies the member, provider, procedure code and modifiers, start and end dates, and units or dollars; MMIS matches every claim line against it.
Claims outside the authorized dates, above the remaining units, or under a different code deny (commonly CO-197, CO-198, or CO-119); the fix is an amendment before the service, not a rebill after it.
ARMHS needs authorization above 300 hours per calendar year as of September 2026 and above 200 hours from January 1, 2027; CFSS must be authorized by the lead agency no later than 40 calendar days from the assessment (Minn. Stat. § 256B.85, subd. 8).
Track remaining units per authorization in real time and request changes from the case manager or the review agent before the units or dates run out.

MHCP prior authorization and waiver service agreements are two different approvals that do the same job on a claim. Each tells the Minnesota Department of Human Services (DHS) claims system, MMIS, which member, provider, procedure code, date span, and units Minnesota Health Care Programs (MHCP) will pay for. When a claim line matches, it pays. When it falls outside the dates, exceeds the units, or uses a different code, it denies.

The two paths start in different places. A waiver, alternative care, home care, or Community First Services and Supports (CFSS) service is authorized when the lead agency case manager enters a service agreement in MMIS, and DHS sends the provider a service authorization letter. A state plan service that needs prior authorization, such as Adult Rehabilitative Mental Health Services (ARMHS) above the annual threshold or Early Intensive Developmental and Behavioral Intervention (EIDBI), is requested by the provider on the MHCP Authorization Form (DHS-4695) and decided by the medical review agent, Acentra Health.

This guide covers the difference, how the authorization travels to the claim, what happens when units run out or dates lapse, ARMHS, EIDBI, and CFSS as examples, tracking remaining units, and requesting changes, as of September 2026.

Service agreement versus prior authorization

	Waiver service agreement	MHCP prior authorization
Who creates it	Lead agency case manager or care coordinator (county, Tribal nation, or managed care organization)	The provider requests it; the medical review agent decides
Where it lives	A service agreement in MMIS with a line item per service	An authorization record in MMIS tied to the DHS-4695 request
What a line contains	Procedure code and modifiers, provider, rate, begin and end dates, units or dollars	Procedure code, up to four modifiers, diagnosis, start and end dates, units, rendering provider NPI or UMPI
How the provider learns of it	Service authorization letter (SAL) in the SAL folder of the MN-ITS mailbox	Written notice from the review agent or MHCP; medical authorization letters in the PAL folder
Who fixes an error	The case manager, who is responsible for the accuracy of the SA in MMIS	The provider files a change to the existing authorization on DHS-4695
Typical services	Waiver services, alternative care, home care, PCA, CFSS, adult day services	ARMHS above the threshold, EIDBI, medical services, equipment and supplies

The MHCP HCBS waiver manual states the principle plainly: waiver services require prior authorization from a case manager in the form of a completed service agreement, and the case manager is ultimately responsible for making sure the SA is accurate when it is entered in MMIS. The provider's duty is to check the letter on receipt. DHS's waiver billing guidance tells providers to contact the case manager if the rate, procedure codes, or begin and end dates on the SA are incorrect, and to bill a date span only when services were delivered on every date in the span.

How the MHCP prior authorization request works

The MHCP Authorization Form (DHS-4695) is the general request. It asks for the pay-to provider's NPI or UMPI and taxonomy code, the member's ID number, whether this is a change to an existing authorization and its PA number, and one service line block per requested service: procedure code, up to four modifiers, diagnosis codes, start and end dates, units, and the rendering provider NPI or UMPI. Supporting documentation goes with it.

Several programs add their own form. ARMHS requests above the threshold use the ARMHS authorization form (DHS-4159A) with DHS-4695. EIDBI requests attach the individual treatment plan (DHS-7109) and the comprehensive multi-disciplinary evaluation. The EIDBI billing codes guide and the ARMHS billing guide cover what each program's packet must contain.

Requests go to the medical review agent. As of September 2026 that is Acentra Health, formerly Keystone Peer Review Organization (KEPRO), through its Atrezzo provider portal or by fax. The MHCP Provider Manual authorization chapter sets the clock:

Step	Timeline
Initial action (approve, deny, or pend for more information)	Within 5 business days of receipt
Pending status when more information is needed	At least 10 calendar days
Final action after the information is received	Within 3 business days
Notice of the decision	Written notice to the provider and the member
EIDBI CMDE or ITP review (effective January 1, 2026)	Within 7 calendar days; provider has 10 calendar days to answer a pend

A pended request that is not answered can be administratively denied, so calendar the pend deadline the day the notice arrives.

How the authorization travels to the claim

MMIS does not read the note or the treatment plan. It matches the claim line against the authorization by member, provider, procedure code and modifiers, date of service, and units. DHS's MMIS claim screen training describes the prior authorization number field as showing the service agreement associated with the claim, and MN-ITS carries the same field on its 837P claim screen. In a batch 837P the number goes in REF*G1; the 837P claim guide shows where.

Four things have to agree for the line to pay:

The code and modifiers on the claim line match the code and modifiers on the authorization line. T1019 authorized with one modifier and billed with another does not match.
The date of service falls inside the authorization's begin and end dates.
The units billed to date, including this claim, do not exceed the authorized units for that line.
The provider on the claim is the provider on the authorization, with the rendering worker enrolled and affiliated on the date of service.

An approved authorization is still not a guarantee of payment. The member must be eligible on the date of service, which is why the MHCP eligibility verification guide pairs with this one, and the service must be documented before the claim goes out.

When units run out or dates lapse

A claim line outside the authorization denies. On the 835 remittance the common codes are CO-197 (precertification or authorization absent), CO-198 (precertification or authorization exceeded), and CO-119 (benefit maximum reached); the exact code varies by payer. The MHCP claim denials guide explains how to read them.

Timing is the point. Services delivered after the units are exhausted or after the end date, and before an amendment is approved, are generally not payable, and rebilling matches the same exhausted line. The fix is an amendment requested before the shortfall: ask the case manager to increase the units or extend the dates on the service agreement, or file DHS-4695 marked as a change to the existing authorization with the PA number. If the member's needs changed, a revised service delivery plan or treatment plan goes with the request.

Compliance note: if you deliver a service you know is unauthorized because the amendment is pending, document that decision and do not bill it until the amendment is approved with a begin date that covers it. Billing against a lapsed authorization and hoping the amendment is backdated is how an authorization problem becomes a program integrity problem.

Three examples: ARMHS, EIDBI, and CFSS

ARMHS

As of September 2026, the DHS ARMHS provider manual requires authorization for more than 300 hours per calendar year of H2017, H2017 HM, and H2017 HQ combined, requested on DHS-4695 with DHS-4159A. Laws of Minnesota 2026, chapter 121, adds Minn. Stat. § 256B.0623, subd. 15, effective January 1, 2027: no more than four hours per week per recipient, a maximum of 18 hours per month, and prior authorization above 200 hours per year. Track both thresholds now, with an alert early enough to submit the request before the client crosses the line. The ARMHS 2027 changes guide covers the transition.

EIDBI

EIDBI is authorized per treatment plan, and the request has to show the frequency, intensity, and duration of each service. Authorized observation and direction (97155) should be approximately 20 percent of total authorized intervention time unless a different proportion is clinically justified in the ITP, and for services requested on or after January 1, 2026 the 97155 request must include individual clinical justification of medical necessity.

CFSS

CFSS is a service agreement program. Under Minn. Stat. § 256B.85, subd. 8, all CFSS must be authorized before services begin, and the authorization must be completed as soon as possible after the assessment and no later than 40 calendar days from the date of the assessment. Subd. 5 requires the assessor to communicate the results and any authorizations in writing within ten business days, and subd. 5a allows a temporary agency-model authorization of no more than 45 days without a full assessment. The letter arrives in the SAL folder of the MN-ITS mailbox, and the CFSS billing guide walks through the four checks that turn it into payment.

Tracking remaining units

Authorization tracking is a running balance, not a filing task. The number that matters is the projected balance at the end date, because that is what tells you whether to request an amendment this month.

Field	Why it matters
Authorized units and dollars per line	The ceiling MMIS enforces
Begin and end dates	Lines outside the span deny regardless of units
Units billed and accepted	The balance MMIS has already consumed
Units documented, unbilled	Will consume balance when billed; must fit
Units scheduled to the end date	Shows the shortfall before it happens
Amendment requested and status	Prevents two people asking the case manager for the same change

Review the balance weekly for every active authorization, with an alert set early enough for the case manager or review agent to act.

Requesting changes

For a service agreement, the request goes to the case manager, who is responsible for changes to the member's SA. Send the specific line, the current and requested units and dates, and the reason, with the revised service delivery plan or support plan if the need changed. Confirm the change by reading the new service authorization letter.

For an MHCP prior authorization, file DHS-4695 with the change box checked and the existing PA number, list only the lines that change, and attach the updated treatment plan or clinical justification. For MCO members, the plan's own authorization process applies; MCOs align their rules with DHS guidance but run their own portals and timelines.

How Trustora helps

Trustora stores every service agreement and prior authorization as line items with the code, modifiers, dates, and units MMIS will match against, and keeps the running balance: units billed, units documented but unbilled, and units scheduled. The compliance engine's pre-claim gate holds any claim line that falls outside the authorization's dates, code, or remaining units before it is submitted, and alerts staff when a scheduled service would exhaust the balance.

The platform covers ARMHS, 245D, PCA/CFSS, EIDBI, and adult day services, so ARMHS hour thresholds, EIDBI treatment plan authorizations, and CFSS service authorization letters are tracked in one place, and the authorization number is carried onto the 837P automatically. See the claims and compliance features for how authorizations, eligibility, and documentation are checked together.

Frequently asked questions

What is the difference between a service agreement and MHCP prior authorization?: A service agreement is the lead agency's authorization for waiver, alternative care, home care, PCA, and CFSS services. The county, Tribal nation, or managed care case manager enters it in MMIS with line items for each service, provider, rate, date span, and unit total, and DHS sends the provider a service authorization letter. MHCP prior authorization covers state plan services that DHS requires be approved in advance; the provider requests it on the MHCP Authorization Form (DHS-4695) and the medical review agent, Acentra Health, decides it.
How does the authorization get onto the MHCP claim?: MMIS matches each claim line against the authorization or service agreement by member, provider, procedure code and modifiers, date of service, and units. The MN-ITS 837P claim information screen has an authorization number field, and an 837P batch carries the number in REF*G1. Whether MHCP requires the number for a given service is stated in the MN-ITS 837P user guide for that service. The MHCP Authorization Form (DHS-4695) itself asks for the same elements per service line: procedure code, up to four modifiers, diagnosis, start and end dates, units, and the rendering provider NPI or UMPI.
What happens when authorized units run out or the dates lapse?: MHCP pays only claim lines that fall inside the authorization's date span and within its remaining units for that procedure code. A line beyond those limits denies, typically with claim adjustment reason code CO-197 (authorization absent), CO-198 (authorization exceeded), or CO-119 (benefit maximum reached). Services delivered before an amendment is approved are usually unpayable, so the provider must ask the case manager to amend the service agreement, or file a change request on DHS-4695, before the units or dates are exhausted.
How long does MHCP prior authorization take?: The MHCP Provider Manual authorization chapter says the medical review agent, Acentra Health, takes initial action, meaning approve, deny, or pend for additional information, within five business days of receipt. If more information is required, the case is placed in pending status for at least 10 calendar days, and the agent takes final action within three business days after the information arrives. The review agent or MHCP sends written notice of the decision to the provider and the member. For EIDBI, Acentra reviews a CMDE or ITP within seven calendar days as of January 1, 2026.
How quickly must a CFSS service authorization be completed?: Under Minn. Stat. § 256B.85, subd. 8, all community first services and supports must be authorized by the commissioner or the commissioner's designee before services begin, and the authorization must be completed as soon as possible after the assessment and no later than 40 calendar days from the date of the assessment. Subd. 5 requires the assessor to communicate results and authorizations in writing within ten business days, and subd. 5a allows a temporary agency-model authorization of no more than 45 days.
Does an approved authorization guarantee MHCP payment?: No. An approved service agreement or MHCP prior authorization confirms that the service is authorized for that member, provider, code, date span, and unit total. Payment still depends on the member being eligible on the date of service, the provider being enrolled and affiliated, the service being delivered and documented before the claim, and the claim matching the authorization line. For PCA and CFSS, the visit must also be verified in the HHAeXchange EVV aggregator.

Sources and further reading

Cite this article

Trustora Editorial Team. (2026, September 9). Service agreements and MHCP prior authorization: how they drive claims. Trustora. https://trustora.com/blog/mhcp-service-agreements-and-prior-authorization

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This article is general information for Minnesota agencies, not legal, clinical, or billing advice. Minnesota DHS policy changes often. Confirm current requirements in the MHCP Provider Manual, the Minnesota Statutes, and DHS provider notices before acting on anything here.