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Moving Home Minnesota (MHM) Provider Enrollment

Revised 12-31-2014

  • New Enrollment
  • Add Services
  • Processing Timelines
  • Ongoing Reporting Requirements
  • MHCP Data Privacy Notice
  • New Enrollment

    To enroll to provide MHM services follow the steps below:

    1.

    Use the Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638) to report the service(s) you plan to provide and your qualifications to provide the service(s).

    2.

    Verify to ensure that none of your employees are on the Office of Inspector General (OIG) Exclusion list. Keep this for your own records.

    3.

    Verify to ensure that no person or entity identified on the Disclosure of Ownership and Control Interest of an Entity (DHS-5259) or any other employees are on the MHCP Enrolled Provider Excluded Provider Lists as an excluded group or individual provider.

    4.

    Contract with the lead agency as appropriate for services listed on the AC/HCBS Waiver and Moving Home Minnesota Programs Lead Agency Enrollment Request Form (DHS-6383).

    5.

    Ensure your agency initiates background studies for all direct care staff as required.

    6.

    Complete and fax the following forms to MHCP Provider Enrollment at (651) 431-7462:

  • • Home and Community-Based Services (HCBS) Waiver and Alternative Care (AC) Programs – Provider Enrollment Application (DHS-4015)
  • MHCP Provider Agreement (DHS-4138)
  • Disclosure of Ownership and Control Interest (DHS-5259)
  • Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638)
  • • Establish your Direct Deposit/Electronic Funds Transfer
  • • Proof showing you are qualified to provide the services including but not limited to:
  • • A copy of the contract from the lead agency
  • • Copies of licenses, certifications and registrations when appropriate
  • • The AC/HCBS Waiver and Moving Home Minnesota Programs Lead Agency Provider Enrollment Request Form (DHS-6383) when appropriate
  • • Assurant statements as appropriate (see the Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638) to determine which services require an assurance statements and a link to the appropriate assurance statement for that service)
  • Processing Timelines

    MHCP processes new enrollment requests in the order received. We will process the request and provide a response within 30 days. Responses include: pending for more information, approval and denials. You must wait until Provider Enrollment processes the information to determine if it is complete or filled out correctly.

    If MHCP approves the initial enrollment request, the provider applicant will receive a confirmation (Welcome) letter, including information about registering for MN–ITS. All providers must register and use MN–ITS for receiving mail and submitting all transactions electronically with MHCP.

    Add Services

    To add additional MHM services to your current enrollment record:

    1.

    Use the Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638) to report the service(s) you want to provide and report your qualifications to provide the service(s)

    2.

    Communicate with the lead agency to ensure your contracts include the new service as appropriate

    3.

    Complete and fax the following to MHCP Provider at 651-431-7462:

  • • Requesting for MHCP to add the service(s) to your file
  • • Proof showing you are qualified to provide the services
  • • Assurance statements, as appropriate (see the Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638) to determine which services require an assurance statements and a link to the appropriate assurance statement for that service)
  • Moving Home Minnesota – Transition Planning, Transition Coordination and Demonstration Case Management Providers – Applicant Assurance Statement (DHS-3879) to enroll to provide Transition Planning and Coordination
  • Moving Home Minnesota - Supported Employment Service Providers – Applicant Assurance Statement (DHS-3873) to enroll to provide Supported Employment Services
  • MHCP will process all requests in the order received and provide a response within 30 days.

    Ongoing Reporting Requirements

    MHCP requires all providers to notify us any time a change occurs. Report any changes by completing the appropriate forms below and faxing to MHCP Provider Enrollment at (651) 431-7462:

  • Individual Practitioner Profile Change Form (DHS-3535) to report change of individual provider name, address, affiliation, etc.
  • Organization Profile Change Form (DHS-3535A) to report change in affiliated providers, address, etc.
  • Disclosure of Ownership and Control Interest (DHS-5259) 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) to add or remove electronic RA to or from a provider or billing organization
  • EFT bank change form (PDF) to report changes to your direct deposit information
  • MHCP will process the change information and notify the agency if any further documentation is necessary to continue or maintain enrollment with MHCP in relation to the changes.

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