Moving Home Minnesota (MHM) Enrollment Criteria and Forms

Revised: April 4, 2024

How to Enroll

Pay the application fee if a federal employer identification number (FEIN) is used, or attach proof that the fee was paid to either Medicare or another state for the same location and for the same services. Use the MHCP Provider Screening Fee Collections System to pay the fee online. Providers must pay the fee before applying to Minnesota Health Care Programs (MHCP).

Review the MHCP Service Combinations for HCBS (DHS-8371) (PDF) for a list of different Home and Community-Based Services enrollment record types.

Providers who wish to enroll or reenroll with MHCP, can do so in one of the following ways:

· Use the Minnesota Provider Screening and Enrollment (MPSE) portal and upload the following:

· A copy of the contract from the lead agency (for contracted case management services only)

· Copies of licenses, certification, and registrations, if indicated in MPSE

· Use the HCBS Programs Service Request (DHS-6638) (PDF) as a guide to identify specific credentials required based on services provided.

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO In-Network Provider Agreement (DHS-8355) (PDF)

· Request for Licensing Agency ID Number (DHS-3891) (PDF), if applicable. See Background Study for more details.

· Proof of completion of the HCBS Waiver and AC Provider Training 101. See HCBS Waiver and AC Provider Training 101 Proof of Completion for a list of acceptable forms of proof.

· A copy of your general liability insurance certificate, if indicated in MPSE

or

Fax the following documents for each location providing services to MHCP Provider Eligibility and Compliance at 651-431-7493:

· HCBS Programs Service Request (DHS-6638) (PDF) to report the service(s) you want to provide and to determine the qualifications needed to provide those service(s). Submit a copy of required credentials, certification, assurance statements and registrations.

· HCBS – Provider Enrollment Application (DHS-4015) (PDF)

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO Provider In-Network Agreement (DHS-8355) (PDF)

· Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF)

· EFT Supplier ID Notification (DHS-3725) (PDF) if you wish to be paid through electronic funds transfer (EFT) (optional)

· Request for Licensing Agency ID Number (DHS-3891) (PDF), if applicable. See Background Study to determine if applicable.

· A copy of the contract from the lead agency (for contracted case management services only)

· A copy of the general liability insurance certificate, if applicable. See General Liability Insurance Certificate to determine if applicable.

· Proof of completion of the HCBS Waiver and AC Provider Training 101. See HCBS Waiver and AC Provider Training 101 Proof of Completion for a list of acceptable forms of proof.

· EFT Supplier ID Notification (DHS-3725) (PDF), to be paid through electronic funds transfer (EFT) (optional). See number 4 in Enrollment with Minnesota Health Care Programs (MHCP) in the MHCP Provider Manual.

Review and keep a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF).

MHCP will process documents in order of date received. Whether enrolling using the MPSE portal or by fax, allow 30 days for processing. We will send a “request for more information” letter if we need additional information. We will send the request for more information letter via U.S. mail (or in the provider’s MN–ITS mailbox, if one has been created) listing what needs to be done to complete the enrollment.

Adding Services to Current Enrollment Record

To add additional MHM services to your current enrollment record:

1. Use the MPSE portal or fax the HCBS Programs Service Request (DHS-6638) (PDF) to add the requested services and to submit qualifications to provide the services.

Include the appropriate assurance statements. See the HCBS Programs Service Request (DHS-6638) (PDF) to determine which services require an assurance statement and for a link to the appropriate assurance statement for that service.

2. Communicate with the lead agency to ensure your contracts include the new service.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services federal provider screening regulations.

MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all the required forms and documents listed in the How to Enroll section of this page.

We recommend using the MPSE portal and following the Revalidation instructions in the MPSE User Manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original “Welcome” letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome letter.

Refer to Revalidation in the Provider Screening Requirements section of the MHCP Provider Manual for important information, including timelines, about the revalidation process and impacts to your enrollment. MHCP will terminate enrollment for providers who do not meet the revalidation timelines.

Review the Frequently Asked Questions for HCBS revalidation.

Reporting Changes

The provider must notify MHCP any time a change occurs. Refer to Changes to Enrollment in the Enrollment with Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual for details.

MHCP will process the change request in the order received and will notify the agency if any more documentation is necessary to maintain enrollment with MHCP.