Children’s Residential Treatment Enrollment Criteria & Forms

Revised: August 3, 2023

To enroll as a children’s residential treatment (CRT) facility with Minnesota Health Care Programs (MHCP), a CRT facility must meet all of the following:

· Be licensed by the state of Minnesota to provide children’s mental health residential treatment services

· Be under clinical supervision of a mental health professional

· Be under contract with a lead county

How to Enroll

Providers who wish to enroll 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. If enrolling through 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 lead agency contract for children’s residential treatment

· Copy of current CRT facility license

or

Submit Forms via Fax

Complete the following documents 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 Managed Care Organization In-network Provider Agreement (DHS-8355) (PDF)

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

· Copy of a current CRTF license

· Copy of lead agency contract for children’s residential treatment

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

Revalidation

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

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 Enrollment with Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual.

Legal References

Minnesota Statutes 253C.01 (Reporting by Residential Treatment Programs Required)
Minnesota Rules 9545.1035
Minnesota Rules 9505.0045 (Residents of Institutions for Treatment of Mental Diseases)
Code of Federal Regulations, title 42, section 440.160 (Inpatient psychiatric services for individuals under age 21)