• For members who change MH-TCM case managers within the same MH-TCM agency, please complete the form and include the new MH-TCM case manager’s information.

Discharge/Termination notification dates include: 

  • Members who are discharged from MH-TCM
  • Members who transfer to another MH-TCM agency or from one case manager to another within the same agency
  • Members who terminate from Hennepin Health's health Plan
  • Member denial

Fax this form to Hennepin Health's Medical Administration: 612-677-6222

Questions? Call Provider Services at 612-596-1036, press 2


Mental Health Targeted Case Management (MH-TCM) changes from a prior authorization to prior notification 

Effective Aug. 1, 2010, Hennepin Health no longer requires a prior authorization for MH-TCM services. 

In lieu of requesting prior authorization, MH-TCM providers are required to submit a notification form at the following times: 

  • Prior to delivery of MH-TCM services
  • When the MH-TCM case is closed
  • When MH-TCM services end through Hennepin Health
  • When the MH-TCM case manager changes within the same agency

Notification also is required for members who are discharged from MH-TCM, transferred to another MH-TCM agency, transferred from one case manager to another within the same agency, terminated from Hennepin Health, or denied MH-TCM services.


After Aug. 1, 2010, requests that are submitted for prior authorization will be treated as a notification if the information required on the notification form is included in the request for prior authorization.

In lieu of prior authorization, Hennepin Health Medical Administration will be conducting periodic audits of providers’ compliance with this requirement and other federal and state MH-TCM requirements.

Member types CPT codes Modifiers Telephone modifiers
Adult (PMAP) T2023 HE U4
Adult (FQHCF)* T1017 HE N/A
Adult MNCare (FQHCF)* T2023 HE N/A
Child (PMAP) T2023 HE HA N/A
Child (FQHCF)* T1017 HE HA N/A
Child MNCare (FQHCF)* T2023 HE HA N/A

PMAP: Prepaid Medical Assistance Program

FQHCF: Federally Qualified Health Care Facilities

* Includes Indian Health Services/tribally owned and operated facilities (IHS/638 facilities)

All required fields must be entered prior to clicking on 'View/Print PDF' to create a PDF.  The PDF may automatically download depending on your browser's settings.