Rehabilitation Agency Enrollment Criteria and Forms

Revised: February 14, 2023

A rehabilitation agency is a provider certified by Medicare to provide restorative and specialized maintenance therapy in an integrated multidisciplinary rehabilitation program. Services may also include social or vocational adjustment services. Medicare-certified rehabilitation agencies must provide services at one of the following:

· A site surveyed by the Minnesota Department of Health and certified according to Medicare standards

· A site that meets state fire marshal standards, as documented in the providers' records

· The member’s residence

Minnesota Health Care Programs (MHCP) does not enroll individual therapists employed by rehabilitation agencies. Rehabilitation agencies are responsible to ensure and maintain proper credentialing of therapists they employ.

Enrollment Criteria

Rehabilitation agencies who wish to enroll with MHCP or make enrollment requests can do so in one of the following two 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:

· Provider Agreement (DHS-4138) (PDF)

· Copy of Medicare Certification as Rehabilitation Agency or CORF from U.S. Department of Health and Human Services

· MHCP provider screening fee payment or proof the fee was paid to another state is required if enrolling as a Comprehensive Outpatient Rehabilitation Facility (CORF)

or

· Complete the following documents required to enroll as a rehabilitation agency 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 if enrolling as a CORF

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

· Provider Agreement (DHS-4138) (PDF)

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

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

· Copy of Medicare Certification as Rehabilitation Agency or CORF from U.S. Department of Health and Human Services

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 explaining what you need to do to complete your enrollment.

Revalidation

MHCP is required to follow the Centers for Medicare & 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

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 256B.0625 (Covered Services)
Minnesota Rules 9505.0385 (Rehabilitation Agency Services)
Minnesota Rules 9505.0390 (Rehabilitative and Therapeutic Services)
Code of Federal Regulations, title 42, section 440.130 (Diagnostic, screening, preventive, and rehabilitative services)