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PCA Provider Agency Enrollment

Revised: 04-14-2014

Initial Enrollment
Annual Review

Ongoing Reporting Requirements

MHCP Data Privacy Notice
(DHS-6287)

Initial Enrollment

Your initial PCPO/PCA Choice application must include all items listed under Initial Application in this checklist. Owners, managing employees and qualified professionals are required to attend PCA agency training before completing the enrollment process. Any additional business sites/locations must also submit a complete application.

Complete and submit the following information and documents to apply as a PCPO/PCA Choice provider agency before training:

  • MHCP PCPO/PCA Choice Agency Enrollment Application (DHS-4022)
  • • Enter all agency personnel into the Office of Inspector General (OIG) Exclusion list to verify they are not on the list
  • • Verify to ensure any individual or entity identified on the Disclosure of Ownership form (DHS-5259) or any other other employees are not on the MHCP Enrolled Provider Excluded Provider Lists as an excluded group or individual provider
  • Disclosure of Ownership and Control Interest (DHS-5259)
  • Qualified Professional (QP) Acknowledgement (DHS-4022C)
  • • Background Study (see Instructions for DHS Background Studies (Included with DHS-4022 )
  • • Request for Licensing Agency ID Number (included with DHS-4022 )
  • Direct Deposit Authorization for Electronic Funds Transfer (EFT)
  • MHCP Provider Agreement (DHS-4138) and one or both of the following:
  • Provider Agreement Addendum – PCPO (DHS-4022A)
  • Provider Agreement Addendum – PCA Choice Provider (DHS-4022B)
  • PCA Agency Personnel List and Affiliation(s) (DHS-6041)
  • • Copy of certificate of registration with the Office of the Secretary of State of Minnesota
  • • Attend training. MHCP will notify you after Provider Enrollment processes the above documents to inform you about the need to have the required persons attend PCA Steps for Success training.
  • • Fax the following information after training:
  • PCA Agency Applicant Assurance Statement (DHS-6005)
  • Designation of PCA Billing Person (DHS-6000)
  • • Copy of certificate of liability insurance
  • • Copy of Workers’ Compensation insurance (not required for Medicare-certified or Class A licensed agencies)
  • • Copy of fidelity bond in the amount of $20,000
  • • Copy of PCA Agency Surety Bond (DHS-6033). The Surety bond must be in the amount of $50,000 for first time enrolling providers

  • **Medicare-certified home health agencies may submit the MHCP Organization – Provider Enrollment Application (DHS-4016A) if also doing services other than PCA; yet If providing PCA services through the enrolled home health agency must also follow the initial enrollment process above.

    Annual Review

    MHCP must review PCA agencies (including Medicare-certified/Class A-licensed agencies who provide PCA services) once every year for continued enrollment. MHCP will notify agencies of their annual review and its requirements. Providers have 30 days to submit required documentation. MHCP will not approve service authorizations or pay claims for services provided, if the annual review information is not submitted within 30 days of the notification.

    At a minimum, MHCP will require the following at annual review:

  • • Copy of current fidelity bond
  • • Copy of the renewed PCA Agency Surety Bond (DHS-6033) in one of the following amounts (effective for any bonds renewed on and after 7/1/2013):
  • • $50,000 for revalidation/annual review if the provider’s PCA payments from Medicaid in the previous calendar year were $300,000 or less
  • • $100,000 for revalidation/annual review if the provider’s PCA payments from Medicaid in the previous calendar year were more than $300,000
  • • Copy of workers’ compensation insurance (excluded for Class A licensed/Medicare Certified Home care agencies)
  • • Copy of current liability insurance coverage
  • • New Qualified Professional (QP) Acknowledgement (DHS-4022C)
  • • New Disclosure of Ownership and Control Interest (DHS-5259)
  • • New MHCP Provider Agreement (DHS-4138) and one or both of the following:
  • • New Provider Agreement Addendum – PCPO (DHS-4022A)
  • • New Provider Agreement Addendum – PCA Choice Provider (DHS-4022B)
  • • New PCA Agency Applicant Assurance Statement (DHS-6005)
  • • Current PCA Agency Personnel List and Affiliation(s) (DHS-6041)
  • • Current Designation of PCA Billing Person (DHS-6000)
  • • Written record of grievances received by your agency in the previous year and resolutions to those grievances

  • You must also meet ongoing requirements of other state agencies for Minnesota businesses.

    Ongoing Reporting Requirements

    When a change occurs in one of the following:

    Fax the appropriate form (below) to MHCP Provider Enrollment:

    Name of business:

    Group, Facility or Billing Entity MHCP Provider Information Change Form (DHS-3535A)

    Address/phone/fax:

    Ownership (must be reported 30 days before the change occurs)

    (sale of business, add or remove owners, directors, managers, board members, other entities with control interest in the business, etc.)

    Disclosure of Ownership and Control Interest (DHS-5259)

    Provider Entity Sale or Transfer Addendum (DHS-5550)

    Management

    Qualified Supervising Professional

    Qualified Professional (QP) Acknowledgement (DHS-4022C)

    Direct deposit/bank information

    EFT Bank Change Request (PDF)

    Billing person

    Designation of PCA Billing Person (DHS-6000)

    Bonds and insurances

    Copy of new, changed or renewed bonds or insurances. Submit at the time of the change.


    You must also meet ongoing requirements of other state agencies for Minnesota businesses.

    MHCP Provider Enrollment fax: 651-431-7462

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