Skip to: Main content | Subnavigation |
Department of Human Services Department of Human Services  
 
Home and Community Based Services (HCBS) Waiver and Alternative Care (AC) Provider Enrollment

Revised: 03-20-2014




New Enrollment
To enroll to provide HCBS waiver and/or AC programs 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 to determine the qualifications needed qualifications to provide the service(s)

2.

Verify all employees are not on the Office of Inspector General (OIG) Exclusion list. Keep this for your own records.

3.

Verify any individual or entity identified on the Disclosure of Ownership form (DHS-5259) or any other employees are not on the MHCP Enrolled Provider Excluded Provider Lists as an excluded group or individual provider

4.

Have the owner or managerial official complete the required Waiver 101 Training and competency test. Print proof of completion to submit with your applications request.

5.

Submit required background studies that pass, for all owners and managers of the program as required by 245C citation and identified on the Disclosure of Ownership form (DHS-5259.), Also if providing one of the services below, assure and comply with assurance statement requirements to take any action ordered in notice of background study results, provide continuous direct supervision of each staff beginning January 1, 2014, until DHS issues a notice of the study results maintain employee records, maintain compliance with the requirements of MS 245C in the service assurance statement:

• Housing Access Coordination
• Assistive Technology Evaluation
• Homemaker Cleaning
• Independent Living Skills Therapies
• Family Counseling (part of the Family Training and Counseling Service)
• Caregiver training and education/coaching and counseling (if direct contact with client)
• Customized Living/24-Hour Customized Living
• Residential Care Services
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)
• Designation of HCBS Waiver or AC Program Billing Person (DHS-6855) if required, see AC and HCBS Waiver Programs Training Requirements for requirements and exemptions.
• Proof showing the owner or manager completed Waiver 101, if required see AC and HCBS Waiver Programs Training Requirements for requirements and exemptions. The provider can submit a copy of their training transcript showing the Waiver Provider 101 Exam as “mastered” under status.
• Copy of your liability insurance certificate naming “DHS PE” as a certificate holder on the document, with the following address listed: PO Box 64987, St Paul, MN 55164-0987 if providing any of the following services:
• Any service that requires you to have a 245D program license
• Foster Care funded by the EW or AC programs (unless family foster care covered by 245.814)
• Adult Day Care
• Customized Living
• Residential Care
• 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 (for contracted case management services only)
• Copies of licenses/certifications/registrations when appropriate
• The HCBS/AC 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)
• AC Nutritional Services Provider Applicant Assurance Statement (DHS-6189B)
• Adult Day Services Providers Applicant Assurance Statement (DHS6189AA)
• Assistive Technology Provider Applicant Assurance Statement (DHS-6189D)
• Customized Living Providers Provider Applicant Assurance Statement (DHS-6189X)
• Environmental Accessibility Provider Applicant Assurance Statement (DHS-6189G)
• EW/AC Family Caregiver Training and Education Provider Applicant Assurance Statement (DHS-6189H)
• Family Training and Counseling Provider Applicant Assurance Statement (DHS-6189I)
• Homemaker Provider Applicant Assurance Statement (DHS-6189K)
• Home Delivered Meals Provider Applicant Assurance Statement (DHS-6189J)
• Housing Access Coordination Provider Applicant Assurance Statement (DHS-6189N)
• Personal Emergency Response System (PERS) Provider Applicant Assurance Statement (DHS-6189CC)
• Specialized Supplies and Equipment Provider Applicant Assurance Statement (DHS-6189T)
• Transitional Services Provider Applicant Assurance Statement (DHS-6189W)
• Waiver Transportation Provider Applicant Assurance Statement (DHS-6189Y)
• Provider Not Required to Receive a 245D Program License Applicant Assurance Statement (DHS-6189Z) - Used only for services listed on the form.

Background Studies
Providers approved to deliver and provide any of the following services must initiate a background study for each staff person who will have direct contact with persons served by the program. Providers must agree to and comply with all 245C background study requirements as itemized in the service assurance statements. Submit background studies for all employees who will provide the direct care to the recipient:

• Housing Access Coordination
• Assistive Technology Evaluation
• Homemaker Cleaning
• Independent Living Skills Therapies
• Family Counseling (part of the Family Training and Counseling Service)
• Customized Living/24-Hour Customized Living
• Residential Care Services
• Caregiver Training and Education/Coaching and counseling (if direct contact with the client)

You must wait until receiving notice from DHS licensing before allow the person to provide direct care services to the MHCP recipient.

Housing with Services/Specialized Services Locations
HCBS waiver and AC provider locations with registration for either Housing with Services (HWS) or Specialized Services must complete steps 1-4 above for each HWS or specialized services location.


Provider Record Review
MHCP requires any providers who want to continue to provide waiver services and receive reimbursement for these services on or after 1/1/2014 to complete a record review.

During the review process, providers complete and submit the forms listed below to report the services they are currently providing or want to continue to provide and submit the approved service credentials as proof they are qualified to provide the service.

Record Review Documentation
To complete the record review, 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)
• Proof showing you are qualified to provide the services including but not limited to:
• Copies of licenses/certifications/registrations when appropriate
• Copies of proof of professional experience (letters from employers or previous employers)
• The HCBS/AC Lead Agency Provider Enrollment Request Form (DHS-6383) when the provider does not meet any of the service credentials listed yet has been previously approved on a service authorization to provide that service. If the provider has a contractual relationship with more than one lead agency, the provider only has to have the form signed by one of them.
• 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)

Lead agencies
The lead agencies (county/tribal human services) have the following exceptions when completing the record review:
Use “Public 5” to report:

• Ownership code on the application (DHS-4015)
• Entity Code on the Disclosure of Ownership form (DHS-5259)

Counties and tribes do not need to list the county board members yet do need to list the managing employees involved when completing the review for the human services offices. Managing employees are limited to the services the county is enrolling.

MHCP will continue to process record review documentation throughout 2013 and post the date for documentation they are processing on the Waiver/AC Provider Home Page.


Processing Timelines
MHCP processes new enrollment requests in the order received. MHCP processes the request and provides a response within 30 business 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 HCBS waiver and AC programs providers must register and use MN–ITS for receiving mail and submitting all transactions electronically with MHCP.


Add Services
To add additional waiver/AC programs services to your current waiver 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

3.

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

• requesting MHCP to add the service(s) to your file
• Proof showing you are qualified to provide the services
• 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)

MHCP will process all requests in the order received and provide a response within 30 business days.


Ongoing Reporting Requirements
MHCP requires waiver and AC programs service providers to notify MHCP 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.


© 2014 Minnesota Department of Human Services Online
North Star is led by the Office of Enterprise Technology
Updated: 3/20/14 9:09 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page |