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Home and Community Based Services (HCBS) Programs Provider Enrollment

Revised: 03-17-2015

  • • New Enrollment
  • • Training Requirements
  • • Add Services
  • • HCBS Provider Enrollment Revalidation
  • • Processing Timelines
  • • Ongoing Reporting Requirements
  • • MHCP Data Privacy Notice
  • New Enrollment

    MHCP requires providers to enroll each location that is providing and receiving reimbursement for services they provide to MHCP recipients.

    The steps and instructions in this section apply to services for any of the following programs :

  • • Alternative Care (AC)
  • • Essential Community Supports (ECS)
  • • Home and Community Based Waivers (BI, CAC, CADI, DD and EW)
  • To enroll for additional Moving Home Minnesota (MHM) services, see Moving Home Minnesota Provider Enrollment.

    Follow these steps when enrolling to provide AC, ECS or HCBS services:

  • 1. Pay the application fee if you use a Federal Tax Identification Number (FEIN) or attach proof that you paid the fee to either Medicare or another state for the same location and to enroll to provide the same services. Use the MHCP Provider Screening Fee Collections System to pay the fee online. You must pay the fee before applying to MHCP. Refer to the MHCP Provider Screening Requirements for information on application fees.
  • 2. 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 you need to provide the service(s)
  • 3. Verify that none of your employees are on the Office of Inspector General (OIG) Exclusion list. The OIG List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients and the public about individuals and entities who are currently excluded from participation in Medicare, Medicaid and all other federal health care programs. Individuals and entities who have been reinstated will no longer be on the LEIE. MHCP recommends that all providers develop an ongoing process to confirm that the provider and any employees are not on the list. Keep all verifications for your own records.
  • 4. Verify any individual or entity identified on the Disclosure of Ownership and Control Interest of an Entity (DHS-5259) or any other employees are not on the MHCP Enrolled Provider Excluded Provider Lists as an excluded group or individual provider.
  • 5. Have the owner or managerial official complete the required Waiver 101 Training and competency test. Print proof of completion to submit with your application request.
  • 6. If you are applying to provide one of the following unlicensed services, you must submit a background study for all owners and managers identified on the Disclosure of Ownership (DHS-5259). Follow the instructions in the Request for Licensing Agency ID Number (DHS-3891) for each of the following:
  • • Caregiver living expenses
  • • Homemaker basic cleaning
  • • Housing access coordination
  • • ILS therapies
  • All owners and managerial officials must pass the background study for the provider to complete enrollment.

    If providing one of the following services, you must complete an assurance statement. You must then comply with requirements of the assurance statement to take any action ordered in your notice of background study results, provide continuous direct supervision of each staff person beginning Jan. 1, 2014, until DHS issues a notice of the study results, maintain employee records, and maintain compliance with the requirements of MS 245C in the service assurance statement. These services are the following:

  • • Assistive technology evaluation
  • • Caregiver training and education; and coaching and counseling (if direct contact with client)
  • • Customized living and 24-Hour customized living
  • • Family counseling (part of the Family Training and Counseling Service)
  • • Homemaker cleaning
  • • Housing access coordination
  • • Independent living skills therapies
  • • Residential care services
  • 7. Complete and fax the following forms and information for each location providing services to MHCP Provider Enrollment at 651-431-7462:
  • • Home and Community-Based Services (HCBS) – 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.
  • • Background Study – Request for Licensing Agency ID Number (DHS-3891)
  • • Proof showing the owner or manager completed Waiver 101, if required see AC and HCBS Waiver Programs Training Requirements for requirements and exemptions. You can submit a copy of the training transcript showing the Waiver Provider 101 Exam as “mastered” under status.
  • • Copy of your general 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 (unless providing only family foster care or family foster care with in home respite services covered by 245.814)
  • • Foster care funded by the EW or AC programs (unless family foster care covered by 245.814)
  • • Adult day care
  • • Customized living
  • • Residential care
  • • Vendor number, after you establish your Direct Deposit and Electronic Funds Transfer following the instructions given
  • • 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 and registrations when appropriate
  • • The HCBS/AC Lead Agency Provider Enrollment Request Form (DHS-6383) when appropriate
  • • Assurance statements, as appropriate: (see the Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638) to determine which services require an assurance statement and a link to the appropriate assurance statement for that service)
  • • AC Nutritional Services Provider Applicant Assurance Statement (DHS-6189B)
  • • Adult Companion Services Providers Applicant Assurance Statement (DHS-6189C)
  • • Adult Day Services Providers Applicant Assurance Statement (DHS-6189AA)
  • • Assistive Technology Provider Applicant Assurance Statement (DHS-6189D)
  • • Chore Service Providers Applicant Assurance Statement (DHS-6189F)
  • • 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-6189L)
  • • Independent Living Skills Therapy Providers Applicant Assurance Statement (DHS-6189M)
  • • 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 people 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 direct care to the recipient for the following services:

  • • Assistive technology evaluation
  • • Caregiver training and education; coaching and counseling (if direct contact with the client)
  • • Customized living and 24-hour customized living
  • • Family counseling (part of the Family Training and Counseling Service)
  • • Homemaker cleaning
  • • Housing access coordination
  • • Independent living skills therapies
  • • Residential care services
  • You must wait until receiving notice from DHS licensing before allowing the person to provide direct care services to an MHCP recipient.

    Owners and managing employees must complete background study for the following:

  • • Homemaker basic cleaning
  • • Housing access coordination
  • • ILS therapies
  • Lead agencies

    Lead agencies (county and tribal human services) have the following exceptions when completing the enrollment documentation:

  • • Use the code number “5 – Public” on the following forms to report:
  • • the ownership code on the Provider Enrollment Application (DHS-4015)
  • • the entity code on the Disclosure of Ownership and Control Interest of an Entity (DHS-5259)
  • • Counties and tribes do not need to list the county board members, but they do need to list the managing employees involved when completing the review for the human services offices. Managing employees are limited to the services for which the county is enrolling.
  • Housing with Services and Specialized Services Locations

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

    HCBS Provider Enrollment Revalidation

    MHCP requires any providers who want to continue to provide waiver services and receive reimbursement for these services to complete revalidation within every five years. During revalidation, the provider must pay the fees and complete all paperwork requested to continue enrollment.

    MHCP will ask you to complete and submit new enrollment forms to report the services you are currently providing and want to continue to provide. You will also need to submit the service credentials to prove your qualifications to provide the services. The forms you will use are the same forms required when completing new enrollment. MHCP will place a revalidation request letter into the PRVLTR folder of the MN–ITS mailbox of the enrollment file being revalidated.

    Processing Timelines

    MHCP processes new enrollment requests in the order received. MHCP processes the request and provides a response within 30 days. Responses include: pending for more information, approval and denial. 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 or 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 to MHCP Provider Enrollment at 651-431-7462:
  • • A request 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 statement 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 days.

    Ongoing Reporting Requirements

    You must 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 more documentation is necessary to continue or maintain enrollment with MHCP in relation to the changes.

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    Updated: 3/17/15 7:44 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 3/17/15 7:44 AM