Community Mental Health Center Enrollment Criteria and Forms

Revised: August 3, 2023

To enroll with Minnesota Health Care Programs (MHCP) as a community mental health center (CMHC) provider, the CMHC must:

· Be certified as a CMHC (Minnesota Statutes 245I.20)

· Be governed by a community board of directors

· Be a private, nonprofit corporation or public agency

· Pass a site visit at the practice location providing services

· Be approved by the Behavioral Health Division of the Minnesota Department of Human Services (DHS) as a CMHC

How to Enroll

Pay the application fee if you use a federal tax identification number (FEIN) or attach proof that you paid the fee to either Medicare or another state for the same location and to enroll to provide 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. Refer to the MHCP Provider Screening Requirements for information on application fees.

After paying the application fee, CMHCs 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 the following:

· 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 MCO In-Network Provider Agreement (DHS-8355) (PDF)

· Community Mental Health Center Application Assurance Statement (DHS-5748) (PDF)

· 245I.20 certification

· Approval letter from DHS Behavioral Health Division (BHD)

or

Submit Forms via Fax

· Complete and sign the following documents required to enroll as a CMHC and fax your materials, along with the required supporting documents, to MHCP at 651-431-7462.

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

· Community Mental Health Center Application Assurance Statement (DHS-5748) (PDF)

· 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 MCO In-Network Provider Agreement (DHS-8355) (PDF)

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

· EFT Supplier ID Notification (DHS-3725) (PDF)- (optional) if the organization is a pay-to provider and enrolled as a fee-for-service provider.

· I.20 certification

· Approval letter from DHS Behavioral Health Division (BHD)

Review and keep a copy of the MHCP Data Privacy Notice (DHS-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. Postal Service telling you what you need to do to complete your enrollment.

Attestation

CMHC providers are required to annually attest that they meet the certification requirements according to Minnesota Statutes, 256B.0625, subdivision 5. Enrolled CMHC providers must complete and submit the Community Mental Health Center Assurance Statement (DHS-5748) (PDF) by December 31 each year via email to the CMHC mailbox at CMHC.Certification.DHS@state.mn.us.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services 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 Enrollment with Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 245.62 (Community Mental Health Center)
Minnesota Statutes, 245I (Mental Health Uniform Service Standards)
Minnesota Statutes, 245I.02 (Mental Health Clinic)
Community mental health center (CMHC) DHS webpage
Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)
Code of Federal Regulations, title 42, section 440.80 (Private duty nursing services)
Code of Federal Regulations, title 42, section 440.90 (Clinic services)