Child and Teen Checkups (C&TC) Enrollment Criteria and Forms
Child and Teen Checkups (C&TC) providers may be facilities or individuals. Enrolled individual providers can add the service to their existing record, as can facilities of provider types listed under Who needs to enroll on this webpage. You can also enroll a specific C&TC clinic record.
How to Enroll
Providers who wish to enroll a C&TC clinic 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 complete the following items and upload them into MPSE:
Community Health Boards (CHB) clinics can enroll as C&TC clinics as well without being supervised by a physician, but with limitations on what they can bill for. CHBs can only enroll and bill for administrative services. To enroll as these, please upload the following:
or
Submit Forms via Fax
Complete the following documents and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.
Community Health Boards (CHB) can enroll as C&TC clinics as well without being supervised by a physician, but with limitations on what they can bill. CHBs can only enroll to bill for administrative services. A CHB who wants to enroll as a C&TC clinic must fax a copy of the CHB’s contract with the Minnesota Department of Human Services.
Review and keep a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF). Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you need assistance.
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 the U.S. Postal Service (or your MN–ITS mailbox, if you have an account) telling you what you need to do to complete your enrollment.
Who needs to enroll
C&TC clinics, and facilities or individuals who would like to bill for C&TC services, need to enroll.
C&TC clinic
To enroll as a C&TC clinic, a facility must be supervised by a physician. The following eligible clinic facility types are:
Facilities
Not all facilities must enroll as a C&TC clinic to provide C&TC services. Facilities that choose not to enroll as a C&TC clinic, but choose to provide C&TC services, must employ an actively enrolled MHCP individual provider. The following facilities may choose to provide C&TC services without enrolling a separate C&TC clinic record:
Individual Providers
To provide C&TC services, MHCP-enrolled individual practitioners must complete the Child and Teen Checkups Provider Agreement (DHS-4646) (PDF) and either fax the enrollment documents to MHCP at 651-431-7462, or upload a copies to the MPSE portal.
The following individual provider types may provide all the components of a C&TC service:
The following individual provider types may provide some of the components of a C&TC service under supervision of a physician or dentist:
Revalidation
MHCP is required to follow the Centers for Medicare & Medicaid Services 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 Changes to Enrollment in the Enrollment with Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual for details.
Changes in ownership should be reported 30 days in advance, and require new copies of all enrollment documents, a new screening fee payment, along with a signed copy of the Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF).
Additional Resources
Minnesota Statutes, 256B.04, subdivision 1b (Duties of State Agency, Contract for administrative services for American Indian children)
Code of Federal Regulations, title 42, section 440.40 (Nursing facility services for individuals age 21 or older [other than services in an institution for mental disease], EPSDT and family planning services and supplies)
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