Intermediate Care Facilities (ICF/DD) Enrollment Criteria and Forms

Posted: November 30, 2021

How to Enroll

ICF/DD providers who wish to enroll with Minnesota Health Care Programs (MHCP) must follow these steps.

1. Pay the application fee if you use a federal employer identification number (FEIN), or attach proof that you paid the fee 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. You must pay the fee before applying to MHCP.

· This provider type must have National Provider Identifier (NPI). Contact the National Plan and Provider Enumeration System (NPPES) if you need to obtain an NPI.

2. Register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal. Upload the following forms to the MPSE portal:

· MHCP Provider Agreement (DHS-4138) (PDF)

· A copy of the ICF/DD contract signed with DHS

or

Complete the following forms required to enroll as an ICF/DD provider and fax the forms and supporting documents to MHCP Provider Eligibility and Compliance at 651-431-7493.

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

· MHCP Provider Agreement (DHS-4138) (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). See number 4 of Enrollment Process in the MHCP Provider Manual.

· Copy of your general liability insurance certificate naming “DHS Provider Eligibility and Compliance” as a certificate holder on the document, with the following address listed: PO Box 64987, St. Paul, MN 55164-0987.

· Proof showing you are qualified to provide the services, including but not limited to:

· Supervised Living Facility license

· 245D Home and Community Based Services license

· Residential Services Facility license

· A copy of the ICF/DD contract signed with DHS

· A copy of Centers for Medicare & Medicaid Services (CMS-1539)

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

If you have further questions regarding the licensing standards of Minnesota Statutes, chapter 245D services, call DHS licensing help desk at 651-431-6624. The help desk is available Monday through Friday 8 a.m. to 4 p.m.

Revalidation

MHCP is required to follow the Centers for Medicare and Medicaid Services (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

You must notify MHCP any time a change occurs. 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.

MHCP will process the change information and notify the agency if any more documentation is necessary to continue or maintain enrollment with MHCP in relation to the changes.

Additional Resources

Minnesota Statutes, 256B.4912 (Home and Community-Based Waivers; Providers and Payment)
Minnesota Statutes, 256B.04 (Duties of State Agency)