{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["RequestForWaiverECP","Instructions","Additional","Data"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":0,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"RequestForWaiverECP","index":0,"n_rows":42,"n_cols":21,"rows_kept":42,"cut":false,"hidden":false,"merged":[[18,2,18,10],[27,2,27,7],[28,2,28,7],[20,2,20,19],[26,0,26,25],[27,11,27,12],[28,11,28,12],[27,8,27,10],[28,8,28,10],[15,20,15,25],[16,20,16,25],[17,20,17,25],[10,0,10,25],[14,0,14,25],[38,4,38,25],[39,4,39,25],[40,0,40,25],[41,3,41,25],[18,11,18,19],[18,20,18,25],[21,0,21,25],[22,3,22,25],[23,0,23,25],[24,3,24,25],[25,3,25,25],[27,13,27,25],[28,13,28,25],[33,13,33,25],[31,13,31,25],[19,0,19,25],[1,1,1,2],[15,11,15,19],[16,11,16,19],[17,11,17,19],[15,2,15,10],[16,2,16,10],[17,2,17,10],[4,1,4,10],[7,1,7,2],[13,2,13,19],[7,3,7,10],[5,1,5,12],[6,1,6,12],[11,13,11,14],[2,1,2,2],[9,1,9,25],[32,13,32,25],[37,4,37,25],[32,2,32,7],[33,2,33,7],[33,8,33,10],[33,11,33,12],[36,3,36,25],[34,3,34,7],[29,13,29,25],[30,2,30,7],[30,8,30,10],[30,11,30,12],[30,13,30,25],[31,8,31,10],[31,11,31,12],[32,8,32,10],[32,11,32,12],[29,2,29,7],[29,8,29,10],[29,11,29,12],[31,2,31,7]]}
[]
[]
[]
[]
[null,"MANAGED CARE SYSTEMS"]
[null,"P.O. Box 64975, St. Paul, MN 55164-0975"]
[null,"Telephone: 651-201-5100"]
[null,"Email:",null,"health.managedcare@state.mn.us"]
[]
[20,"Request for Waiver (ECP)"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Plan Year:",null,2025]
[]
[null,"1.","Name and Title of Person Submitting this Document:"]
[]
[null,null,"Carrier",null,null,null,null,null,null,null,null,"Name Network",null,null,null,null,null,null,null,null,"Network ID"]
[null,null,"<enter carrier>",null,null,null,null,null,null,null,null,"<enter network>",null,null,null,null,null,null,null,null,"<enter network id starts with MNN>"]
[null,null,"Name",null,null,null,null,null,null,null,null,"Title",null,null,null,null,null,null,null,null,"Date"]
[null,null,"<enter name>",null,null,null,null,null,null,null,null,"<enter title>",null,null,null,null,null,null,null,null,{"$f":"TODAY()","v":"2024-03-18"}]
[]
[null,"2.","By submitting this form, the above-referenced confirms:"]
[]
[null,null,"A.","That person submitting this request has personal knowledge of the network contracting process involved in this submission, and"]
[]
[null,null,"B.","That access cannot be met for the following ECP categories.  Include the county and reason(s) for not meeting the requirements.  "]
[null,null,null,"It is not necessary to request a waiver in situations where there is no ECP of a required category available in the county:"]
[]
[null,null,"ECP Category",null,null,null,null,null,"County",null,null,"Reason Code",null,"Notes"]
[null,null,"<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,null,"Please use additional sheet if needed"]
[]
[null,null,null,"Reason Codes:"]
[null,null,null,"1.","Provider does not meet carrier's data requirements, utilization review, and quality assurance requirements; or"]
[]
[null,null,null,"2.","Carrier has made a good faith effort to contract with provider(s).  Please provide a statement of what was done to attempt to contract with the provider."]
[]
[null,null,"C.","That if new providers listed in (B) becomes available in the service area, carrier will make a good faith effort to contract with said providers."]

{"sheet":"Instructions","index":1,"n_rows":18,"n_cols":1,"rows_kept":18,"cut":false,"hidden":false,"merged":[[6,0,6,12],[0,0,0,12],[1,0,1,12],[2,0,2,12],[3,0,3,12],[4,0,4,12],[14,0,14,12],[15,0,15,12],[17,0,17,12],[7,0,7,12],[8,0,8,12],[9,0,9,12],[10,0,10,12],[11,0,11,12],[12,0,12,12]]}
[]
["MANAGED CARE SYSTEMS"]
["P.O. Box 64975, St. Paul, MN 55164-0975"]
["Telephone: 651-201-5100"]
["Email: health.managedcare@state.mn.us"]
["Please review the following instructions prior to filling in the ECP Request for Waiver"]
["1) File format: MS Excel"]
["2) Please download the Request for Waiver ECP form. Open document. If you receive a Security warning, click enable content.  Save as type: Excel Macro - Enabled workbook (*.xlsm).  You will need to save this so if you need to make changes to the form you do not need to retype."]
["3) Enter the carrier, network name and network ID. These must match the information in SERFF."]
["4) Enter the name and title of the person submitting the form."]
["5) Pick an ECP category from the drop down menu. Only one category may be listed per line."]
["6)Pick each county that pertains to ECP Category from the drop down menu.  Multiple counties may be selected by picking from the drop down menu each time. If you need to remove a county that you chose, pick the drop down menu and select the county again."]
["7)Pick a reason code from the drop down menu. Only one reason code may be listed per line."]
["8) If you need to add a page, click the Additonal tab at the bottom."]
["9) Ready to submit? Make sure to choose When finished, choose save as: Change from Excel Macro - enabled workbook (.xlsm) to Excel Workbook (.xlsx). Hit save. You may receive a warning that you are saving as a macro-free workbook.  Click yes. This will be a version without the macros enabled to upload) "]
["10) Upload the document. You must upload the document without the macros enabled.  MDH web will not be able to process documents submitted from the Macro - Enabled workbook.  You should have two copies saved on your computer: and Excel Macro - Enabled Workbook (.xlsm) and an Excel Workbook( .xlsx).  Please make sure to upload the Excel Workbook (.xlsx) format."]
[]
["If you have any problems, please send an email to health.managedcare@state.mn.us"]

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["ECP Category",null,null,null,null,null,"County",null,null,"Reason Code",null,"Notes"]
["<select one>",null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
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["Itasca"]
["Jackson"]
["Kanabec"]
["Kandiyohi"]
["Kittson"]
["Koochiching"]
["Lac Qui Parle"]
["Lake"]
["Lake Of The Woods"]
["Le Sueur"]
["Lincoln"]
["Lyon"]
["Mahnomen"]
["Marshall"]
["Martin"]
["McLeod"]
["Meeker"]
["Mille Lacs"]
["Morrison"]
["Mower"]
["Murray"]
["Nicollet"]
["Nobles"]
["Norman"]
["Olmsted"]
["Otter Tail"]
["Pennington"]
["Pine"]
["Pipestone"]
["Polk"]
["Pope"]
["Ramsey"]
["Red Lake"]
["Redwood"]
["Renville"]
["Rice"]
["Rock"]
["Roseau"]
["St. Louis"]
["Scott"]
["Sherburne"]
["Sibley"]
["Stearns"]
["Steele"]
["Stevens"]
["Swift"]
["Todd"]
["Traverse"]
["Wabasha"]
["Wadena"]
["Waseca"]
["Washington"]
["Watonwan"]
["Wilkin"]
["Winona"]
["Wright"]
["Yellow Medicine"]