Service Agreement and Screening Document (SASD) Support Team Portal

Lead agency staff (counties, tribal nations and managed care organizations) use this secure form to contact the SASD Support Team. The SASD team provides MMIS technical assistance for service agreements/authorizations and screening documents for home and community based services, such as:

Waiver programs (BI, CAC, CADI, DD and EW)
The Alternative Care (AC) program
The Essential Community Supports (ECS) program
Medical Assistance (MA) home care services.

Do not use this form for Minnesota Health Care Programs (MHCP) enrollment or policy issues/questions.

Your information

Required field

NAME

EMAIL ADDRESS

PHONE NUMBER

FAX NUMBER

LEAD AGENCY

CASE TITLE

SUBJECT

DESCRIPTION

CASE PMI

WAIVER TYPE

EDIT NUMBER 1

EDIT NUMBER 2

EDIT NUMBER 3

MODIFIER

PROCEDURE CODE

MMIS SERVICE AGREEMENT NUMBER

MMIS SERVICE AGREEMENT LINE ITEM

NEW HIGHER RATE

OLD RATE

MMIS SCREENING DOCUMENT NUMBER

Attach any documentation that would be helpful for us to assist you. Only PDF, Word, Excel, JPG, GIF, PNG, BMP or text files may be uploaded.

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