Personal Care Assistance Technical Change Request Page 2
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1
2Personal Care Assistance (PCA)
Technical Change Request
Purpose of PCA Technical
Recipient Information
Change Request
Enter complete legal name
„
Enter the 8 digit Subscriber ID number (also
To request technical changes and corrections to
„
known as MA number and recipient ID)
existing SAs for some Personal Care Assistance
(PCA) services.
Select PCA Traditional or PCA Choice
„
Enter the date of birth
„
Eligibility
Provider Agency Information
Verify MA eligibility using MN–ITS or call
651-431-4399 or (800) 657-3613.
Enter the PCA Agency name
„
Enter PCA Agency NPI/UMPI
„
Third Party Payers
Enter name and title of the person submitting
„
MA is the payer of last resort. Information
the request
regarding other payers is available through EVS.
Enter the PCA Agency phone number
„
Enter the PCA Agency fax number
„
Form Instructions
Additional Information
Request Type
Enter additional information regarding the
Select the type of change or correction you are
request.
requesting. Refer to Authorization Requirements
in the PCA section of the MHCP Provider Manual
Recipient/Responsible Party Signatures
for additional information.
Required when “New Provider” request type.
Enter the Change/Start and End Dates.
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Parent category: Legal