Renal Dialysis Facility Enrollment Criteria and Forms

Revised: October 16, 2023

To enroll as a renal dialysis provider with Minnesota Health Care Programs (MHCP), the following facility types must have an approval letter from the Centers for Medicare & Medicaid Services (CMS):

· Medicare-approved end stage renal dialysis (ESRD) facilities in hospitals

· Renal transplant centers

· Renal dialysis facilities and centers

· Outpatient hospitals

· Self-dialysis units

· Special purpose renal dialysis facilities

· Medical supply providers that the Department of Human Services (DHS) has approved to provide ESRD services. DHS will approve only those medical suppliers who have provided home dialysis equipment and supplies to Medicare beneficiaries in the past 12 months.

How to Enroll

Renal dialysis providers who wish to enroll with MHCP or make enrollment requests can do so in one of the following ways.

· 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:

· 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).

· The letter from the regional CMS office approving the unit as a dialysis facility

· If the facility is in Minnesota, the CMS 1539

or

· Complete the following documents required to enroll as a CNS and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Confirmation of the MHCP provider screening fee payment or proof the fee was paid to another state or Medicare

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

· 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).

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

· EFT Vendor Number Notification (DHS-3725) (PDF) (optional)

· The letter from the regional CMS office approving the unit as a dialysis facility

· If the facility is in Minnesota, the CMS 1539

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

We process forms in order of date received. Whether enrolling 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 your MN–ITS mailbox or U.S. mail telling you what you need to do to complete your enrollment.

Revalidation

MHCP is required to follow the CMS final federal provider screening regulations.

Refer to Revalidation in the Provider Screening Requirements section of the MHCP Provider Manual for more information about how to complete your revalidation.

Reporting Changes

Report any changes made on a provider record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 144.122 (License, Permit, and Survey Fees)
Minnesota Statutes, 256B.02, subdivision 7 (Vendor of medical care)
Minnesota Rules, 9505.0015 (Definitions)
Code of Federal Regulations, title 42, section 405.2110 (Designation of ESRD networks)