Physician and Physician Clinic Enrollment Criteria and Forms

Revised: November 1, 2023

Physicians may enroll with Minnesota Health Care Programs (MHCP) as individuals or groups.

To enroll as an individual physician with MHCP, the physician must be a medical doctor (MD) or doctor of osteopathic medicine (DO) and be licensed by the Minnesota Board of Medical Examiners or meet the licensure and certification requirements of the state in which they practice.

To enroll as a physician clinic with MHCP, the clinic must employ at least two physicians and may be one of the following:

· A free-standing clinic

· A hospital-based clinic

How to Enroll

Providers 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.

· Upload the 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) in the MPSE portal.

or

Complete the following documents required to enroll for your provider type and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

Physician

The physician must complete and fax the following:

· Physician license

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional), if the individual physician is a pay-to provider

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

Clinic

The clinic must complete and fax the following:

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional), if the physician clinic is a pay-to provider

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

· 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)

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

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 notice or letter telling you 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 Statutes, 147.02 (Examination; Licensing)
Minnesota Rules, 9505.0175 (Definitions)
Minnesota Rules, 9505.0250 (Clinic services)
Code of Federal Regulations, title 42, section 440.50 (Physicians' services and medical and surgical services of a dentist)
Code of Federal Regulations, title 42, section 440.90 (Clinic services)