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Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Enrollment

Revised: 01-11-2017

Enrollment
Processing Timelines

Ongoing Reporting Requirements

MHCP Data Privacy Notice (DHS-6287) (PDF)

Enrollment for EIDBI Providers

CMDE Providers

Follow these steps to enroll as an EIDBI comprehensive multi-disciplinary evaluation (CMDE) provider.

  • 1. Complete and fax the following to Minnesota Health Care Programs (MHCP) Provider Enrollment at 651-431-7462:
  • MHCP Individual Practitioner – Provider Enrollment Application (DHS-4016) (PDF)
  • Minnesota Department of Human Services Provider Agreement (DHS-4138) (PDF)
  • EIDBI Assurance Statement for Comprehensive Multi-Disciplinary Evaluation (CMDE) Providers (DHS-7120A) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • 2. Establish your Direct Deposit and Electronic Funds Transfer
  • MHCP providers adding CMDE services
    To add CMDE services to your current enrollment record, complete and fax the following to MHCP Provider Enrollment:

  • EIDBI Assurance Statement for Comprehensive Multi-Disciplinary Evaluation (CMDE) Providers (DHS-7120A) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • EIDBI Provider Agencies

    Follow these steps to enroll as an EIDBI provider agency.

  • 1. Ensure that your employees are not on the Office of Inspector General (OIG) Exclusion List. Keep this exclusion list for your own records.
  • 2. Ensure that no person or entity identified on the Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) form, or any other employees, are on the MHCP Excluded Provider Lists as an excluded group or individual provider.
  • 3. Ensure your agency initiates a background study for all direct care staff as required.
  • 4. Complete and fax the following to MHCP Provider Enrollment at 651-431-7462:
  • MHCP Organization – Provider Enrollment Application (DHS-4016A) (PDF)
  • MHCP Provider Agreement (DHS-4138) (PDF)
  • Disclosure of Ownership and Control Interest (DHS-5259) (PDF)
  • Assurance Statement for EIDBI Provider Agencies (DHS-7120B) (PDF)
  • EIDBI Assurance Statement for Qualified Supervising Professionals (QSP) (DHS-7120C) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • 5. Establish your Direct Deposit and Electronic Funds Transfer
  • Qualified Supervising Professional (QSP) and Level I, II and III Providers

    Do not enroll as a Level I, II or III provider until your affiliated agency is actively enrolled with MHCP to provide EIDBI services. Level I, II and III providers and QSPs must be affiliated with an actively enrolled EIDBI agency.

    Providers that are currently enrolled as an individual PCA must complete the enrollment applications. MHCP will not add EIDBI services to an actively enrolled individual PCA enrollment record.

    Complete and fax the information indicated for each provider type to MHCP Provider Enrollment at 651-431-7462.

    QSP providers
    To enroll as an EIDBI qualified supervising professional (QSP) provider, complete and fax the following:

  • MHCP Individual Practitioner – Provider Enrollment Application (DHS-4016) (PDF)
  • MHCP Provider Agreement (DHS-4138) (PDF)
  • EIDBI Assurance Statement for Qualified Supervising Professionals (QSP) (DHS-7120C) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • To add QSP services to your current enrollment record, complete and fax the following to MHCP Provider Enrollment:

  • EIDBI Assurance Statement for Qualified Supervising Professionals (QSP) (DHS-7120C) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • Level I providers
    To enroll as an EIDBI Level I provider, complete and fax the following to MHCP Provider Enrollment:

  • MHCP Individual Practitioner—Provider Enrollment Application (DHS-4016) (PDF)
  • MHCP Provider Agreement (DHS-4138) (PDF)
  • EIDBI Assurance Statement for Level I Providers (DHS-7120D) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • To add Level I provider services to your current enrollment record, complete and fax the following to MHCP Provider Enrollment:

  • EIDBI Assurance Statement for Level I Providers (DHS-7120D) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • Level II provider
    To enroll as an EIDBI Level II provider, complete and fax the following to MHCP Provider Enrollment:

  • MHCP Individual Practitioner – Provider Enrollment Application (DHS-4016) (PDF)
  • MHCP Provider Agreement (DHS-4138) (PDF)
  • EIDBI Assurance Statement for Level II (DHS-7120E) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • To add Level II provider services to your current enrollment record, complete and fax the following to MHCP Provider Enrollment:

  • EIDBI Assurance Statement for Level II (DHS-7120E) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Licenses
  • • Certifications
  • • College transcript(s)
  • • Diplomas
  • Level III providers
    To enroll as an EIDBI Level III provider, complete and fax the following to MHCP Provider Enrollment:

  • MHCP Individual Practitioner – Provider Enrollment Application (DHS-4016) (PDF)
  • MHCP Provider Agreement (DHS-4138) (PDF)
  • EIDBI Assurance Statement for Level III Providers (DHS-7120F) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Certifications
  • • Diplomas
  • To add Level III provider services to your current enrollment record, complete and fax the following to MHCP Provider Enrollment:

  • EIDBI Assurance Statement for Level III Providers (DHS-7120F) (PDF)
  • • Proof showing you are qualified to provide EIDBI services, including but not limited to the following:
  • • Certifications
  • • Diplomas
  • Telemedicine services
    All EIDBI CMDE, QSP, Level I, or Level II providers that plan to deliver telemedicine services, must self-attest that they meet all of the conditions of the MHCP telemedicine policy. Please review the Telemedicine criteria.

    To enroll as a CMDE, QSP, Level I or Level II provider, follow the steps listed under Enrollment and include the Provider Assurance Statement for Telemedicine (DHS-6806) (PDF).

    To add telemedicine services to your current enrollment record, complete and fax the Provider Assurance Statement for Telemedicine (DHS-6806) (PDF) to MHCP Provider Enrollment.

    Processing Timelines

    MHCP processes enrollment requests in the order received. We will process the request and provide a response within 30 days. Responses include the following: pending for more information, approval and denial. You will not be able to submit claims for services you provide until Provider Enrollment notifies you that your enrollment request is complete and approved.

    If MHCP approves your initial enrollment request, you will receive a confirmation letter, including information about registering for MN–ITS. You must register for and use MN–ITS to receive mail from and submit electronic transactions to MHCP.

    Ongoing Reporting Requirements

    MHCP requires all providers to notify us when a change occurs. Report changes by completing the appropriate form below and faxing it to MHCP Provider Enrollment at 651-431-7462:

  • Individual Practitioner - MHCP Profile Change Form (DHS-3535) (PDF) to report changes of individual provider names, addresses, ending or adding affiliation to an agency, etc.
  • Organization - MHCP Profile Change Form (DHS-3535A) (PDF) to report changes in affiliated providers, addresses, etc.
  • Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) to report changes in ownership or managing employees with controlling interest (ownership changes must be reported at least 30 days before the change occurs)
  • Electronic Remittance Advice (RA) Request Form (DHS-4718) (PDF) to add or remove electronic remittance advices to or from a provider or billing organization
  • Electronic Funds Transfer (EFT) Bank Change Request to report changes for your direct deposit information
  • MHCP will process change information and notify the agency if any further documentation is needed to maintain enrollment with MHCP.

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    Updated: 1/11/17 2:56 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 1/11/17 2:56 PM