Licensed Independent Clinical Social Worker (LICSW) Enrollment Criteria and Forms

Revised: October 3, 2025

A licensed independent clinical social worker (LICSW) must be licensed by the Minnesota Board of Social Work or a Minnesota Department of Human Services-approved Minnesota tribal license to enroll with Minnesota Health Care Programs (MHCP). A social worker enrolling with MHCP to provide services out of state must be licensed in the state of practice and meet the Minnesota board’s licensing criteria.

How to Enroll

LICSW providers who want 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. You are required to upload the following:

· 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)

· Current license from the state of practice or DHS-approved Minnesota tribal license

or

Submit Forms via Fax

Complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Individual – Provider Enrollment Application (DHS-4016) (PDF)

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the Managed Care Organization In-Network Provider Agreement (DHS-8355) (PDF)

· Current license from the state of practice or from the tribal entity

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

We process forms in the order they are received. Whether enrolling or revalidating using the MPSE portal or by fax, allow 30 days for processing. If we need more information to complete enrollment, we will send a letter requesting more information via the U.S. Postal Service explaining what you need to do to complete your enrollment.

Medicare Enrollment Denials

Most LICSW’s are eligible to enroll with Medicare. If Medicare denies your enrollment as a provider, submit the Medicare denial letter along the Mental Health Professional Applicant Assurance Statement - Medicare Enrollment Denial (DHS-3864) (PDF) to MHCP Provider Eligibility and Compliance. You need to submit DHS-3864 every 18 months to verify your denied enrollment with Medicare. If Medicare approves your enrollment after you’ve been denied, notify MHCP Provider Eligibility and Compliance immediately.

Revalidation

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

MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all required forms and documents listed under How to Enroll to Provider Eligibility and Compliance at 651-431-7462.

We recommend using the MPSE portal and following the instructions in the Revalidation section of the MPSE user manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original Welcome Letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome Letter.

Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.

Reporting Changes

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