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Provider Screening Requirements

Revised: 01-04-2017

MHCP has received additional guidance regarding the provider screening requirements. Review the Revalidation Schedule below in this section for more information.

MHCP temporarily delayed sending revalidation requests for providers eligible to enroll with Medicare.

However, if you have already received a revalidation request from MHCP, you must comply with that request. If you are eligible to enroll with Medicare, even if you are not currently enrolled with Medicare (by choice or through opt-out), and did not yet receive a revalidation request letter, your request is on hold until further notice. MHCP is awaiting additional clarification from the Centers for Medicare & Medicaid Services (CMS) before we send any more requests to providers eligible to enroll with Medicare.

MHCP sent all requests for providers in round 1. We sent revalidation request letters to only those providers in rounds 2 and 3 that have a registered MN–ITS mailbox. Requests for providers not eligible to enroll with Medicare will continue as scheduled. Refer to the Revalidation Schedule.

Continue to visit this page frequently to review the most up-to-date information about the MHCP screening requirements and processes.

  • Risk Levels
  • Revalidation
  • Revalidation Schedule
  • Site Visits
  • Application Fees
  • Paying the Fee
  • Legal References
  • Minnesota Health Care Programs (MHCP) is required to follow the Centers for Medicare & Medicaid Services (CMS) final federal provider screening regulations that were effective March 25, 2011.

    These regulations require you to do the following:

  • • You must revalidate your existing provider enrollment record when notified to do so by MHCP Provider Enrollment.
  • • If you are going through enrollment, reenrollment or revalidation, you are subject to new screening actions based on risk of fraud, waste or abuse of Medicare and Medicaid funding.
  • • If you are considered a moderate or high-risk provider, MHCP will conduct unannounced site visits of your locations.
  • • MHCP will collect application fees before enrollment, reenrollment or revalidation:
  • • For new applications received on and after Oct. 1, 2014
  • • At the time of and before completion of reenrollment or revalidation
  • If you are actively enrolled with and already paid the application fee to Medicare or to another state within the last five years, you are not subject to the fee upon enrollment or revalidation with MHCP.

    Risk Levels

    CMS has established the following three risk levels for providers: limited, moderate and high. It has assigned one of these risk levels to each provider type that enrolls with Medicare.

    MHCP uses the same Medicare risk levels assigned by CMS for provider types that are eligible to enroll with both Medicare and MHCP. For provider types that are not eligible to enroll with Medicare, MHCP has assigned risk levels.

    Refer to the Risk Levels and Enrollment Verification Requirements section of this manual and the CMS Medicare Program Integrity Manual, Screening Categories (PDF) for information.

    Change of Risk Level

    MHCP is required to assign a high risk level to an individual provider or provider organization when any of the following conditions exists:

  • • A payment suspension is imposed because of a credible allegation of fraud, waste or abuse
  • • The provider has an existing Medicaid overpayment
  • • The provider has been excluded by the OIG or another state’s Medicaid program within the last 10 years
  • A provider type is also assigned a high risk level for the first six months after a state Medicaid agency or CMS lifts a temporary moratorium for that provider type.

    Screening Actions

    All providers are subject to some type of screening action. Some screening actions are required for all provider types. Others are specific to provider types with a high or moderate risk level. The table shows the screening actions required for provider types with each risk level.

    Screening Actions Required for Each Risk Level

    Screening Action

    Risk Level Subject to the Screening Action

    Limited

    Moderate

    High

    Provider-specific requirements verification

    X

    X

    X

    Licensure verification (including licensure checks across states, if applicable)

    X

    X

    X

    Database checks (to verify NPI; U.S. Department of Health and Human Services Office of Inspector General [OIG] exclusion; Excluded Parties List System [EPLS] exclusion; death of individual practitioner or of persons who have an ownership or control interest or who are agents or managing employees of the provider; and termination by Medicare or another state’s program)

    X

    X

    X

    Unscheduled or unannounced site visits

    X

    X

    Criminal background check (based on fingerprints*)

    X

    Fingerprinting*

    X

    *CMS has not issued final guidance for fingerprinting requirements. MHCP will not implement these screening actions until they issue guidance.

    Revalidation

    If you are currently enrolled with MHCP, you must revalidate your enrollment record(s) at least once every five years. Revalidation occurs when MHCP notifies you to complete and update all enrollment documents to continue participation with MHCP. Refer to the Revalidation Schedule.

    When your revalidation occurs, MHCP sends you a notice with instructions for revalidation based on your provider risk level and provider type file. Letters will go to each provider record. If you work for an agency, both the individual provider and the agency will get a letter. Note the following requirements for the revalidation process:

  • • You have 30 days from the date on the notice to fax in all required documents.
  • • If MHCP does not receive all required information, MHCP will send you a request for more information (RFMI) notice asking for the remaining required information to complete revalidation. This information is due 30 days from the date on the RFMI notice.
  • • If MHCP does not receive all required information 30 days after the RFMI notice date, MHCP will send you a 60-day notice of termination including provider appeal rights and options for re-enrolling after termination.
  • If you are enrolled as more than one provider type, you will receive a separate notice for each type. If you are consolidated and have more than one file for a provider type, you will receive one notice with instructions to send the required information for each file.

    If you are subject to a fee, you must pay the fee at the time you submit your revalidation documents.

    If you are assigned a high or moderate risk level, you are subject to a site visit. The post-enrollment site visit may occur any time within the five years before your next revalidation. You can continue receiving payments from MHCP while the site visit is pending. When appropriate, MHCP may use the results from a site visit already conducted by Medicare, another state or MHCP, if the visit was completed 12 months before your revalidation.

    Enroll Each Location

    If you have more than one business location that provides a service, you must follow the instructions for new enrollments and enroll each business location at the time of revalidation.

    Your Enrollment May End

    If you do not meet enrollment requirements for revalidation, MHCP will notify you that we have terminated your enrollment. This notice will include your appeal rights. We can terminate your enrollment at revalidation for any of the following screening reasons:

  • • Failure to submit all required documents within the required timeframe
  • • Nonpayment of a required enrollment fee
  • • Failure to meet enrollment qualifications, such as:
  • • Lack of required licensure or certification
  • • Failure to document other requirements of enrollment
  • • Refusal to allow access for a site inspection
  • If you do not submit all required documentation within the required timelines and do not comply with all screening requirements, MHCP may revoke your billing privileges and terminate your enrollment. (Minnesota Statutes, sections 256B.04, subd. 22 and 256B.064).

    PCA Agencies

    If your enrollment with MHCP ends, you must immediately notify the county or counties where your MHCP recipients live. Inform the county that you can no longer be reimbursed for services as an MHCP provider, and that the county should take actions to ensure the safety of the recipients. (Minnesota Statutes, section 626.557). Any terminated personal care assistance (PCA) provider agency, including all named individuals on the current enrollment disclosure form, and known or discovered affiliates of the PCA provider agency, is not eligible to enroll as a PCA agency for two years following the termination. (Minnesota Statutes, section 256B.0659, subd. 23).

    Exceptions

    If you fall under one of the following categories of providers, you are not required to revalidate your enrollment at this time:

  • • Currently enrolled providers of home and community-based services (HCBS) who completed their waiver record review in 2013 and 2014
  • • Providers of services under alternative care (AC) waivers who completed their waiver record review in 2013 and 2014
  • • Providers of day training and habilitation (DT&H) who completed their waiver record review in 2013 and 2014
  • However, if you fall under one of the categories above and are applying to enroll an additional location, the application is a new enrollment that is subject to the full screening requirements.

    If you are enrolling or affiliating an individual PCA provider to a PCA agency, you do not need to take any steps beyond following existing MHCP procedures. The special screening requirements described in this section of the MHCP Provider Manual do not apply to you at this time.

    Revalidation Schedule

    MHCP received additional guidance from CMS on how we may rely on the Medicare screening for revalidation of providers that are active and dually enrolled with both Medicare and MHCP. MHCP must verify certain data elements for both individual and organization providers based on their assigned risk category through the Medicare Provider Enrollment, Chain and Ownership System (PECOS) to consider a provider revalidated. MHCP can rely on the Medicare data if a dually enrolled provider matches the necessary data elements. Providers that have already received a request for revalidation must still comply with that request.

    Refer to the Sub Regulatory Guidance for State Medicaid Agencies and the chart in that document with details about Medicare provider screening elements.

    Once MHCP is able to verify that a provider meets the minimum required data elements, we will send a notice that states their revalidation is complete. If MHCP is unable to verify the minimum required data elements, we will send a revalidation request letter to the provider to submit their revalidation documentation.

    For all other providers that enrolled or re-enrolled with MHCP before May 1, 2012, MHCP will request that you complete your revalidation sometime before March 24, 2016. Refer to the updated MHCP Revalidation Schedule to determine when to expect a revalidation request letter. MHCP will place revalidation request letters into the PRVLTR folder of your MN–ITS mailbox following the schedule in the table below. Refer to the MN–ITS Mailbox User Guide for instructions on using the mailbox.

    If you do not have a registered MN–ITS account, the revalidation request letter will be sent via U. S. Postal Service. If you received your revalidation request letter through the U.S. Postal Service, you need to register your MN–ITS account to be sure you get future notifications. The Welcome Letter you received when you first enrolled has instructions. If you do not have a copy of your Welcome Letter, call the MHCP Provider Call Center to ask for a copy.

    MHCP will continue to add other provider types as their schedule becomes known. Home and Community-Based Services and DT&H providers will begin revalidation after January 2017.

    MHCP Revalidation Actions

    Round 1: April 24, 2015
    We sent notice through MN–ITS and US Postal Service to the following provider types:

  • • Acupuncturists
  • • Allied Dental Professionals, both groups and individuals
  • • Birth Centers
  • • Certified Professional midwifes
  • • Child and teen checkup clinics
  • • Community health clinics
  • • Community health workers
  • • Head Start programs
  • • Hearing aid dispensers
  • • Licensed professional clinical counselors (LPCC’s)
  • • Medical suppliers
  • • Medical transportation
  • • Public health clinics
  • • Rehabilitation agencies
  • Notices went to the following provider types by last name or agency name:

  • • Home Care Nurse Agencies (A-C)
  • • Home Health agencies (R-Z)
  • • PCA Agencies (R-Z and any name beginning with a number)
  • Round 2: June 1 through June 30, 2015
    We sent notice through MN–ITS only to the following provider types:

  • • Ambulatory Surgical Centers
  • • Audiologists
  • • Billing Entity for Physician Services
  • • Clinical Nurse Specialist
  • • Family Planning Agency
  • • Independent diagnostic testing facilities
  • • Independent Laboratory
  • • Independent X-ray
  • • Nurse Midwife
  • • Podiatrists, both group and individuals
  • Notices went to the following provider types by last name or agency name:

  • • Home Care Nurse Agencies (D-N)
  • • Home Health Agencies (I-Q)
  • • PCA Agencies (L-Q)
  • • Physician Clinic (A-E)
  • • Physicians (A-E)
  • • Physician Assistant (A-E)
  • Round 3: July 1 through July 31, 2015
    We sent notice through MN–ITS only to the following provider types:

  • • Psychologist
  • • ICF/DD
  • Notices went to the following provider types by last name or agency name:

  • • Hospital (A-L)
  • • PCA Agencies (E-K)
  • Round 4: October 1 through October 31, 2015
    We sent notice through MN–ITS and US Postal Service to the following provider types:

    * Denotes U.S. Postal Service notice only

  • • Nurse Midwife *
  • • Clinic Nurse Specialist *
  • • Ambulatory Surgery Center *
  • • Billing Entity for Physician Services *
  • • Mental Health Rehab Professional *
  • • Psychologist *
  • • Audiologist *
  • • Independent Diagnostic Testing Facility *
  • • Independent Laboratory *
  • • ICF/DD *
  • • Indian Health Facility
  • • Federally Qualified Health Center
  • • Rural Health Clinic
  • • Children’s Residential Treatment
  • • Community Mental Health Center
  • • Billing Entity for Mental Health
  • • Dietician
  • • Podiatrist – both group and individual *
  • • Chiropractic – both group and individual
  • • Billing Entity for Rehabilitation
  • • Nursing Facility
  • • Institution for Mental Disease *
  • • Renal Dialysis
  • • Optometrist
  • • Pharmacy
  • • Pharmacist
  • • Optician
  • Notices went to the following provider types by last name or agency name:

  • • Hospitals (A-L)*
  • • Hospitals (M-Z)
  • • PCA Agencies (B-D), (Ai-Ax) and (Aa-Ag)
  • • Home Care Nurse Agencies (O-Z)
  • • Home Care Nurse Individuals (M-Z) and (A-L)
  • • Home Health Agencies (E-H) and (A-D)
  • Round 5: November 1 through November 30, 2015
    We sent notice through MN–ITS and US Postal Service to the following provider types:

    *denotes U.S. Postal Service only

  • • Certified Registered Nurse – both group and individual
  • • Licensed Independent social workers
  • • Marriage and Family Therapist
  • • Psychologist *
  • • Physical Therapist
  • • Occupational Therapist
  • • Speech Language Pathologist
  • • Audiologist *
  • • School Districts
  • • Chemical Dependency
  • • Dental – both group and individual
  • • Approved Day Treatment Programs
  • • Target Case Management
  • • Intensive Residential Treatment Services
  • • Hospice
  • • Nurse Practitioner
  • Notices went to the following provider types by last name or agency name:

  • • Physician Clinic (F-K), (L-M), (N-R) and (S-Z)
  • • Physician (F-K), (L-M), (N-R) and (S-Z)
  • • Physician Assistant (F-K), (L-M), (N-R) and (S-Z)
  • Note: If your provider type is not yet listed on the schedule, we will add it once we have determined revalidation dates.

    Site Visits

    If your provider type has a moderate or high risk level, MHCP will conduct pre-enrollment and post-enrollment site visits when you enroll, re-enroll or revalidate enrollment. You must permit MHCP to conduct unannounced on-site inspections of any of your locations to comply with screening requirements.

    MHCP will conduct an unannounced site visit within 60 days of the date we receive notice from DHS’s provider enrollment area that you are enrolling, re-enrolling or revalidating enrollment. If you do not cooperate during a pre-enrollment visit, we will not approve your enrollment application.

    If you deny access to one of your locations during a site visit, we will either not approve your enrollment application or terminate your enrollment.

    Application Fees

    MHCP, like Medicare and all other states’ Medicaid programs, must collect a nonrefundable application fee from “institutional providers of medical or other items or services or suppliers” to fund provider screening costs. If you are an institutional provider and are newly enrolling, re-enrolling or revalidating enrollment, you must pay the application fee. The application fee for 2016 is $554 per practice location. Beginning on Jan. 1, 2017, the fee will increase to $560 per practice location. If you are required to pay a fee, you must pay the fee that applies to the calendar year that we receive your application. We must receive your application fee before we can process your application for enrollment.

    The application fee is determined by CMS and is subject to change every calendar year. CMS publishes the application fee in the Federal Register 60 days before each new calendar year.

    Fees are not required of noninstitutional providers, physicians and nonphysician practitioners, regardless of whether they are in a small-group practice, unless the physician also requests enrollment as a DMEPOS supplier.

    The following providers are nonphysician practitioners:

  • • Anesthesia assistants
  • • Audiologists
  • • Certified nurse-midwives
  • • Certified registered nurse anesthetists
  • • Clinical nurse specialists
  • • Clinical psychologists
  • • Dentists
  • • Dental hygienists
  • • Nurse practitioners
  • • Occupation and physical therapists in private practice
  • • Physician assistants
  • • Psychologists practicing independently
  • • Registered dieticians
  • • Speech language pathologists in private practice
  • Enrolling providers, including those in a presidentially declared disaster area, may request a hardship exception to the application fee. CMS considers requests for hardship exceptions on a case-by-case basis.

    Providers That Are Considered Institutional Providers

    The federal screening law uses the term “institutional provider” differently from the way MHCP has traditionally used that term. According to the federal law, an institutional provider is not limited to hospitals, nursing facilities and similar providers. For this reason, for provider screening purposes, MHCP will consider an institutional provider to be any organizational provider that has a tax identification number (TIN) or federal employer identification number (FEIN). An individual provider who does not have a TIN or FEIN will not be considered an institutional provider.

    Lists of Institutional Providers
    A provider whose provider type appears on the following MHCP or Medicare list is considered an institutional provider that must pay the application fee, if the provider is required to have a TIN or FEIN. A provider whose provider type does not appear on either of the following lists does not need to pay the fee.

    List of MHCP Institutional Providers
    The following MHCP institutional provider types are subject to the application fee. If your provider type is listed, and if you have not already paid the screening fee, then you are subject to the application fee for each new enrollment, reenrollment and revalidation for each of your locations or provider type files enrolled with another state in the past five years.

  • • ARMHS
  • • Birth centers
  • • CTSS
  • • DT&H
  • • Early Intensive Developmental and Behavioral Intervention (EIDBI) agencies
  • • HCBS and AC program providers (excludes those without a federal tax identifier)
  • • Institutions for mental disease (IMD)
  • • Intermediate care facilities for people with developmental disabilities (ICF/DD)
  • • IRTS
  • • PCA provider agencies (PCPOs)
  • • Providers of chemical health services
  • • Providers of children’s residential treatment
  • • Providers of day treatment
  • • Providers of home care nursing
  • • Providers of Individualized Education Programs (IEP) services
  • • Providers of targeted case management
  • • Providers of special transportation (nonambulance)
  • • Public health nursing organizations
  • List of Medicare Institutional Providers
    Medicare defines the following provider types as institutional providers. If your provider type is listed, and if you have not already paid the screening fee for each of your locations to another state or Medicare in the past five years, you are subject to the application fee for each location for each new enrollment, reenrollment and revalidation.

  • • Ambulance service suppliers
  • • Ambulatory surgical centers (ASCs)
  • • Community mental health centers (CMHCs)
  • • Comprehensive outpatients rehabilitation facilities (CORFs)
  • • DMEPOS
  • • End-stage renal disease facilities
  • • Federally qualified health clinics (FQHCs)
  • • Histocompatibility laboratories and independent clinical laboratories
  • • Home health agencies (HHAs)
  • • Hospice providers
  • • Hospitals (including critical access hospitals)
  • • Independent diagnostic testing facilities (IDTFs)
  • • Indian Health Services (IHS)
  • • Mass immunizers (roster billers)
  • • Pharmacies
  • • Providers of outpatient physical therapy, occupational therapy or speech pathology services
  • • Portable x-ray suppliers (includes mammography centers)
  • • Rural health clinics (RHCs)
  • • Skilled nursing facilities (SNFs)
  • If a physician is also enrolled as a DMEPOS supplier to furnish items to his or her patients, the physician must pay the application fee for DMEPOS.

    Multiple Provider Files

    If you enroll as more than one kind of institutional provider, you must pay a fee for each enrollment.

    If you are currently enrolled as a provider and have multiple practice locations, you must enroll and pay a fee for each location.

    Paying the Fee

    MHCP has developed a web-based system for providers to submit their fee payments. The system allows you to pay for multiple locations in one transaction and accepts the following forms of payment:

  • • Credit card
  • • Debit card
  • • Electronic check
  • To access the system, click the following link: https://payments.dhs.state.mn.us/HCProviderPayment.aspx. Determine which payment type to use based on your business transactions, card authorizations and usage limits. For questions about usage and limits, contact your financial institution.

    If you are actively enrolled with and already paid the fee to Medicare or another state within the last five years, you are not subject to the fee upon enrollment or revalidation with MHCP.

    Review the screening requirements in this section of the MHCP Provider Manual to determine whether you are required to pay a fee.

    Hardship Exemption

    You may request an exemption from the application fee by completing the Hardship Exemption Request Form (DHS-3901) (PDF) and submitting it along with documentation supporting the request with the MHCP enrollment application for new enrollment, reenrollment and revalidation requests. If you have multiple locations requesting hardship exemption, you must complete and submit a separate form for each.

    On the Hardship Exemption Request Form, describe the hardship and why the hardship justifies an exemption. Supporting documentation must clearly identify your provider name and location requesting the exemption, and the documentation must show evidence of hardship supporting your request. Supporting documents may include, but are not limited to, financial balance sheets, tax return documents, income expense reports, and any other document showing proof of financial hardship for your business location. MHCP will forward your request to the Centers for Medicare & Medicaid Services (CMS) for a determination. CMS may request additional information before making a final determination.

    MHCP will not process your application until CMS has granted or denied your request and MHCP receives the final determination from CMS. If CMS grants the hardship exemption, MHCP will process your application. If CMS denies the hardship exemption, you must pay the application fee within 30 days of the date of the denial. If MHCP does not receive the fee within 30 days, we will deny the application.

    Denial and Terminations

    Any provider whose enrollment application is denied approval or whose enrollment is terminated by MHCP, Medicare or another state Medicaid agency must undergo screening and pay all applicable application fees again to enroll or re-enroll with MHCP.

    At the time of new enrollment, reenrollment or revalidation, MHCP will deny application approval for or terminate the enrollment of a provider if any person with 5 percent or more direct or indirect ownership or control interest in the provider, any agent, or any managing employee:

  • • Does not submit a set of fingerprints within 30 days of the request (applies only to owners)
  • • Is determined under state or federal law to have committed an offense that has resulted or would result in an exclusion from, suspension of or termination of participation in Medicare, Medicaid or the Children’s Health Insurance Program (CHIP)
  • • Is terminated for cause on or after Jan. 1, 2011, by Medicare or any other state’s Medicaid program or CHIP (CMS is establishing a portal for uploading and downloading information on these terminations)
  • • Does not submit timely and accurate disclosure information
  • • Fails to cooperate with all screening methods
  • • Fails to provide access to provider locations for site visits
  • • Falsifies information on an application
  • If MHCP denies approval for a provider’s application for cause or terminates a provider’s enrollment for cause and the provider later submits an application for a new enrollment or re-enrollment, the provider must again undergo screening and pay all applicable application fees.

    Legal References

    Final federal provider screening regulations, published Feb. 2, 2011
    42 Code of Federal Regulations, section 455.450

    Minnesota Statutes, section 256B.04, subdivisions 21 and 22

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