DHS-6979-ENG 3-26 (2.1.4)

MnCHOICES Help Desk Contact Form

Lead agencies (counties, tribal nations and managed care organizations) use this form to request support or help with the MnCHOICES Application or questions about policy and rates. Before submitting this request, consult with your agency’s MnCHOICES or rates mentors as well as review:

MnCHOICES mentors will use this form to:

Submit a technical inquiry – a problem or issue with the MnCHOICES application
Submit a policy inquiry – a problem or issue with the use of policy or practice in the MnCHOICES application
Submit a MnCHOICES request – example assessor certification questions and reports request.

NOTE:

If your question is about the Medicaid Management Information System (MMIS) use the Service Agreement and Screening Document (SASD) Support Team Portal
If your inquiry is not related to MnCHOICES, use the DSD Contact Form.

DATE SUBMITTED

CONTACT INFORMATION

ORGANIZATION NAME (LEAD AGENCY YOU WORK ON BEHALF OF)

LOCATION NAME (AGENCY YOU ARE EMPLOYED BY)

FIRST NAME

LAST NAME

PHONE NUMBER

Are you submitting this form on behalf of another user?

Yes

ADDITIONAL USER INFORMATION

MnCHOICES USER ID

FIRST NAME

LAST NAME

PHONE NUMBER

ISSUE DESCRIPTION

Is this a critical issue? Is the issue a work stoppage disrupting major business functions and/or widely impacting users (like an outage)?

Yes

ISSUE TITLE (BRIEFLY DESCRIBE THE PROBLEM)

ISSUE DESCRIPTION

IDENTIFYING INFORMATION

If this request does not involve the information asked for in the first two fields, enter "N/A."

PERSON ID

FORM ID

QUESTION TYPE

Technical (i.e., related to the MnCHOICES Application)

Policy or practice (e.g., assessment, support planning, waivers/AC/ECS, homecare, PCA/CFSS/CDCS, rates, managed care, training, homecare, etc.)

Other (e.g., reports, assessor certification questions, etc.)

TECHNICAL

PROBLEM DATE

PROBLEM TIME

FORM TYPE

OTHER

ENVIRONMENT

Training

Testing

Production

BROWSER

Microsoft Edge

Chrome

Firefox

Other

BROWSER OTHER

WHO EXPERIENCED THE PROBLEM?

Only this user

Multiple users

DESCRIBE THE PROBLEM

STEPS TAKEN BEFORE THE PROBLEM OCCURRED (i.e., STEPS TO REPRODUCE PROBLEM)

WHAT, IF ANYTHING, HAVE YOU ALREADY TRIED TO RESOLVE THE PROBLEM?

OTHER COMMENTS

This question is related to: (Select one. If you need to ask about both areas, submit an additional form.)

User access

Reports and data

Other

What is your question or request?

Additional information (What is your suggested solution or answer? Do you have tentative next steps? Describe any attachments you are including or any additional information you would like us to understand.)

ATTACHMENTS

PROVIDE SCREENSHOTS OR DOCUMENTATION FOR EXAMPLES IF APPLICABLE

Only PDF, Word, Excel, JPG, GIF, PNG, BMP or HTML files may be uploaded.

DESCRIBE ATTACHMENTS

MnCHOICES Help Desk Contact Form

CONTACT INFORMATION

ADDITIONAL USER INFORMATION

ISSUE DESCRIPTION

IDENTIFYING INFORMATION

TECHNICAL

POLICY OR PRACTICE

ATTACHMENTS