Hospital Enrollment Criteria and Forms

Revised: November 3, 2023

To enroll as a hospital with Minnesota Health Care Programs (MHCP), an inpatient and outpatient hospital services facility must be licensed and meet the definition of a hospital, or if outside of Minnesota, the hospital must be designated by the Centers for Medicare & Medicaid Services (CMS) to provide acute care. The hospital must be qualified to participate in Medicare, unless it only provides emergency services. If the hospital is a Federal Indian Health Service, it must be designated by the federal government to provide acute care.

How to Enroll

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

Online MPSE portal

Register to access the Minnesota Provider Screening and Enrollment (MPSE) Portal and complete your enrollment online using the MPSE portal. Also, upload the following in the MPSE portal:

· A completed, signed, and initialed Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF).

· A copy of the facility’s state hospital license

· Proof of enrollment with Medicare

· Proof of payment of the MHCP enrollment fee or proof the fee was paid to another state or Medicare

Complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462

· Organization - Provider Enrollment Application (DHS-4016A) (PDF)

· A completed, signed, and initialed Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF)

· Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) - All owners, board members, and managing employees must be disclosed

· A copy of the facility’s state hospital license

· Proof of enrollment with Medicare

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional)

· Proof of payment of the MHCP enrollment fee or proof the fee was paid to another state or Medicare

A hospital that is currently enrolled as an MHCP provider may become qualified to participate in the Hospital Presumptive Eligibility (HPE) program by completing the following documents and meeting the following requirements:

· Hospital Presumptive Eligibility Provider Assurance Statement (DHS-3887) (PDF)

· Required training: Hospitals will need to submit the names and HPE learning center identification number of at least two hospital staff members who have passed the HPE100 web-based training on Hospital Staff Who Passed DHS Hospital Presumptive Eligibility Online Training Course (DHS-3889) (PDF).

· Agree to follow MHCP policies and procedures for eligibility determinations. Refer to the HPE Policy Guide (DHS-7267) (PDF) and the HPE Procedures Guide (DHS-7267A) (PDF).

· Help people, approved for HPE by the hospital, complete and submit the online application through MNsure.org or the paper Application for Health Coverage and Help Paying Costs (DHS-6696) (PDF). Hospitals may also offer them information on other help available, such as through a MNSure navigator.

· Meet established performance standards:

· 80 percent of the people approved for HPE by the hospital must go on to file an application through MNsure either online or on paper within 30 days of the end of the HPE coverage period.

· 80 percent of the people who file a MNsure application are determined eligible for Medical Assistance (MA).

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

We process forms in the order they are received. Allow 30 days for processing whether enrolling or revalidating using the MPSE portal or by fax. We will send a request for more information letter through U.S. Postal Service or to your MN–ITS mailbox if we need more information to complete your enrollment.

Depending on additional services a hospital may provide, the hospital may also apply as one of the following types of providers:

· Chemical health – requires county contract for a specified time period to provide chemical health services

· Critical access hospital – review the Minnesota Department of Health’s Critical Access Hospitals webpage for criteria

· Swing bed – Must be approved by the Minnesota Department of Human Services Long-Term Care Division

· Nursing facility

· Rehabilitative services

Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 with questions.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services final 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 required forms and documents listed in the How to Enroll section to DHS.

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 Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, about the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.

Reporting changes

Report any changes made on a provider record to MHCP Provider Enrollment. Refer to Changes to Enrollment in Enroll with MHCP under Provider Basics in the MHCP Provider Manual for details.

Changes in ownership should be reported 30 days in advance, and require new copies of all enrollment documents, along with a signed copy of the Provider Entity Sale or Transfer Addendum DHS-5550 (PDF).

Legal References

Minnesota Statutes, 144.696, subdivision 3 (Health Care Cost Information, Definitions, Hospital)
Minnesota Statutes, 144.50 (Hospitals, Licenses; Definitions)
Minnesota Statutes, 256B.057, subdivision 12 (Presumptive eligibility determinations made by qualified hospitals)
Minnesota Statutes, 9505.0015, subpart 21 (Medical Assistance Eligibility, Definitions)
Minnesota Rules, 9505.0300 (Medical Assistance Payments, Inpatient Hospital Services)
Code of Federal Regulations, title 42, section 435.1110 (Presumptive eligibility determined by hospitals)
Code of Federal Regulations, title 42, section 440.10 (Services: General Provisions, Definitions)
Code of Federal Regulations, title 42, section 482.1 (Conditions of Participation for Hospitals, General Provisions)