Billing

Provider Documentation

Providers must keep required statutory documentation per MN Rules part 9505.2175 in member’s file. Documentation includes the following:

1. Evidence that PCAs met training requirements
2. Copy of the service plan form the county PHN/county case manager
3. Care plan (updated at least once a year)
4. Backup and emergency plan information
5. Service Authorizations
6. Copies of all notices sent to member about PCA services going over authorized hours
7. Documentation showing the agency verified each PCA does not appear on the OIG exclusion list
8. Supervision documentation
9. Written agreements if PCA Choice
10. DHS background studies
11. Responsible party information
12. PCA services recorded using the PCA Time and Activity Documentation (DHS-4691) timecard or a DHS-approved alternate form. Timecards must include:
    1. The statement, “It is a federal crime to provide false information for Medical Assistance payment” above the member/responsible party and PCA signatures
    2. Instructions for the member to draw a line through dates and times if services were not received
    3. Member:
       1. Name
       2. Date of birth (DOB)
       3. PrimeWest Health member number/PMI
       4. Signature (member’s or responsible party)
       5. Date
    4. PCA:
       1. Name
       2. National Provider Identifier (NPI) or UMPI
       3. Signature
       4. Date

The PCA must document all activities provided, including the following:

1. Date of service (DOS) (day/month/year)
2. Arrival and departure times (including a.m./p.m. notation)
3. Shared care ratio (staff to member)
4. Shared care location
5. Daily total time
6. Total time for all PCA services documented on the timesheet

Personal care provider records must document the following:

1. The physician’s initial statement of need for personal care services and that it was received by PrimeWest Health prior to the start of services;
2. That the statement of need has been reviewed by the physician at least once every 365 days;
3. PrimeWest Health care plan completed by the supervising RN that details the nurse’s instruction to the PCA;
4. PrimeWest Health notice of prior authorization, which identifies the amount of personal care service and RN supervision authorized for the member; and
5. Whether or not the member is in a shared care arrangement.

In a shared care arrangement, the documentation requirements must be met separately for each member.

The following daily documentation must be made by each PCA of services provided to the member:

1. Member’s name;
2. Name of the PCA providing services;
3. Day, month, and year the personal care services were provided;
4. Total number of hours spent providing personal care services;
5. Time of arrival and time of departure of the PCA at the site where services were provided;
6. Personal care services provided;
7. Notes by the PCA regarding changes in the member’s condition, documentation of calls to the supervising nurse, and other notes as required by the supervising nurse;
8. PCA’s signature; and
9. Member’s signature, stamp, mark, or the responsible party’s signature, if the member requires a responsible party.

Each member record must also document the following:

1. Authorization by the member’s responsible party, if any, for personal care services provided outside the member’s residence;
2. Authorization by the responsible party, who is a parent of a minor member or a guardian of a member, which is approved and signed by the supervising nurse, to delegate to another adult the responsible party function for absences of at least 24 hours but not more than six days; and
3. Supervision by the supervising nurse, including the date of the provision of supervision of personal care services, if supervision by the supervising nurse is requested.

Personal Care Assistant (PCA) Service Procedure Codes

^**When a member has a change in condition, the provider is responsible for notifying the PHN, who will in turn contact the member/responsible party to determine if an increase in PCA service units is necessary.

For non-contracted providers, Service Authorization is required in addition to a Service Agreement.

All other Healthcare Common Procedure Coding System (HCPCS) code and modifier combinations still apply to PCA claims. Any applicable modifier payment adjustments will be made during claims adjudication.

If needed, the county PHN will recommend a temporary increase (up to 45 days) to the currently approved PCA service units. PrimeWest Health will send providers a new Service Agreement, indicating the additional, temporarily increased PCA service units.

For shared PCA services (1:2 and 1:3), the Service Agreement will authorize procedure code T1019 and state that the shared care option was selected. The provider must use appropriate modifier to indicate shared care for billing.

Claims for individual PCA line items:

1. Bill only for the individual PCA, submit supervising QP and nursing charges on separate claims.
2. Include the individual rendering NPI for the PCA on each line item.

Claims for QP supervision or nursing services:

1. Bill separate from PCA claims
2. Do not list the nurse’s individual NPI as the rendering provider. Submit claims using the facility NPI.

Additional information about PCA services can be found in the DHS Community-Based Services Manual (CBSM).

To find a specific PCA-related form, visit the DHS PCA forms page.

Tiered Rates and Wage Floors

Tiered reimbursement rates for all PCA agencies

Reimbursement rates for PCA services provided by a direct support worker are increased based on the experience level of the specific worker providing those services. PCA provider agencies must use the increase in the reimbursement rate for wages and wage-related costs for the direct support worker.

Tiered minimum wages, or wage floors for PCA Choice

The hours of PCA services a direct support worker has provided since July 1, 2017, determines the minimum wage floor for direct support workers in the PCA Choice model. Direct support workers in PCA Choice must be paid at least the appropriate minimum wage on the tiered wage schedule starting January 1, 2025.

For more information, review the PCA and CFSS tiered rates and wage floors web page.

PW_11-19_581
Updated_02/23/2026