MN DHS Fraud Reporting Tool

Tips
Record Information

Tips

Please check to acknowledge that you have read and understood the Tennessen Warning above

Information About You

Your Role

Other Role

If MCO, what plan?

State Agency

If DHS - what admin/area

County

Please Read
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 Other

Other Program

Specific Program, if known (i.e. PCA, ICS, etc.)

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

Minnesota Provider Number

Provider Address

National Provider Identifier Number

Additional Providers/Provider information

Recipient First Name

Recipient Last Name

Recipient ID

Recipient Date of Birth

Unknown Recipient Date of Birth

Recipient Address

Recicpent City

Recipient State

Recipient Zip Code

Record Information

From Name*

Subject*

Program Text

From Address*

Complaint received via

Status