Form DHS-4795-ENG Quality Differential Rate Request Form - Minnesota

What Is Form DHS-4795-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is the DHS-4795-ENG Quality Differential Rate Request Form?
A: The DHS-4795-ENG Quality Differential Rate Request Form is a document used in Minnesota to request a quality differential rate.

Q: What is a quality differential rate?
A: A quality differential rate is a payment rate that is higher than the standard rate for a service in recognition of the higher quality or additional services provided.

Q: Who can use the DHS-4795-ENG form?
A: The DHS-4795-ENG form is used by providers in Minnesota who want to request a quality differential rate for their services.

Q: What information is required in the form?
A: The form requires information such as the provider's name, contact information, service type, and the reason for requesting a quality differential rate.

Q: Is there a deadline for submitting the form?
A: The form should be submitted at least 60 days prior to the requested effective date of the quality differential rate.

Q: What happens after the form is submitted?
A: After the form is submitted, the department will review the request and make a determination on whether to approve or deny the quality differential rate.

Q: Can a provider appeal the department's decision?
A: Yes, a provider can appeal the department's decision regarding the quality differential rate.

Q: Who should I contact for more information?
A: For more information about the DHS-4795-ENG form and the quality differential rate request process, you can contact the Minnesota Department of Human Services.