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Limited Authorization (LA) Dental Hygienists

Revised: 07-10-2013

  • Enrollment Criteria
  • Covered Services
  • Billing
  • Additional Resources
  • Limited authorization (LA) dental hygienists must be employed or retained by one of the following MHCP-enrolled groups:

  • • Health care facility
  • • Program (such as Head Start)
  • • Nonprofit organization
  • Individual LA dental hygienists are not eligible for direct MHCP reimbursement.

    Individual LA dental hygienists must enroll with a group affiliation to receive reimbursement at the group level for all dental hygiene services rendered to MHCP enrollees. As part of this process, MHCP requires individual NPIs and affiliation with one or more of these enrolled group providers.

  • • Individual dental hygienists must indicate their group affiliations on their applications
  • • Enrolled groups must add their enrolled LA dental hygienists to their provider file using the Organization MHCP Provider Profile Change Form (DHS-3535A) (PDF)
  • • Groups not yet enrolled must include individual group members, including LA dental hygienists
  • For LA dental hygienists providing services to enrollees in a managed care organization (MCO), contact the MCO for enrollment requirements and coverage.

    Enrollment Criteria

    LA dental hygienists must be licensed by the Minnesota Board of Dentistry and have a collaborative agreement registered with the Board of Dentistry.

    LA dental hygienists must complete, sign and fax the following forms to MHCP Provider Enrollment at (651) 431-7462:

  • MHCP Provider Application (DHS-4016) (PDF)
  • MHCP Provider Agreement (DHS-4138) (PDF)
  • MHCP Limited Authorization Dental Hygienists Assurance Statement (DHS-6025) (PDF)
  • • Copy of the collaborative agreement
  • MHCP will notify applicants of the enrollment status within 30 days of receiving the completed and signed documents.

    Covered Services

    MHCP reimburses for covered dental services within the scope of practice of the LA hygienist as identified in Minnesota Statute 150A.10 Subd. 1a.


    Bill all services completed in a limited authorization capacity using the following:

  • • 837D format
  • • Individual LA dental hygienist NPI as the rendering provider
  • • Appropriate health care facility, program (such as Head Start), or non-profit NPI as the pay-to provider
  • Additional Resources

    Minnesota Statutes 150A.10 subd. 1a Limited authorization for dental hygienists

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