Hospice Enrollment Criteria and Forms

Revised: November 3, 2023

To enroll as a hospice provider with Minnesota Health Care Programs (MHCP), the hospice must be licensed as a hospice provider by the Minnesota Department of Health (MDH); and must be certified by Medicare as a provider of hospice services unless it exclusively serves pediatric patients.

How to Enroll

Hospice providers who want to enroll or reenroll with MHCP, can do so in one of the following two ways.

Online MPSE Portal

Register to access the Minnesota Provider Screening and Enrollment (MPSE) Portal and complete your enrollment online using the MPSE Portal. You will be required to upload a:

· Completed, signed and initialed copy of the Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or Managed Care Organization In-Network Provider Agreement (DHS-8355) (PDF)

· Copy of the facility’s hospice license

· MHCP fee payment or proof fee was paid to another state or Medicare

or

Submit Forms via Fax

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)

· Completed, signed and initialed copy of the Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or Managed Care Organization In-Network Provider Agreement (DHS-8355) (PDF)

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

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

· A copy of the facility’s hospice license

· MHCP fee payment or proof fee was paid to another state or Medicare

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

We process forms in the order they are received. Whether enrolling or revalidating using the MPSE portal or by fax, allow 30 days for processing. If we need more information to complete your enrollment, we will send a request for more information letter via U.S. Postal Service (or your MN–ITS mailbox, if you have an account) telling you what we need or what you need to do to complete your enrollment.

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 under How to Enroll to Provider Eligibility and Compliance at 651-431-7462.

We recommend using the MPSE portal and following the instructions in the Revalidation section of 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, 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 Eligibility and Compliance. Refer to the Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

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

Additional Resources

Minnesota Statutes, 256B.0625, subdivision 22 (Covered Services - Hospice care)
Minnesota Rules, 9505.0297 (Hospice Care Services – Medical Assistance payments)
Minnesota Rules - 9505.0446 (Hospice Care Payment Rates and Procedures)
Balanced Budget Act of 1997
Code of Federal Regulations, title 42, section 1396a (State plans for medical assistance)