Regional Treatment Center Enrollment Criteria and Forms

Revised: January 6, 2023

To be enrolled as a regional treatment center (RTC) with Minnesota Health Care Programs (MHCP), an organization must be Medicare-certified, and licensed by the health department in the state they practice.

Enrollment Criteria

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.

Regional treatment centers 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)

· Proof of Medicare certification

· Copy of license

or

· Complete the following documents required to enroll as an RTC and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

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

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

· MHCP Provider Agreement (DHS-4138) (PDF)

· Proof of Medicare certification

· Copy of license

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional)

Regional Treatment Centers are required to be Medicare certified and have a Medicare number. Regional Treatment Centers also must be licensed by the Health Department of the home state.

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 148.624, subdivision 1 (Licensure; Renewal, Dietetics)
Minnesota Statutes 148.624, subdivision 2 (Licensure: Renewal, Nutrition)