Ambulatory Surgical Center Enrollment Criteria and Forms

Revised: October 24, 2023

To enroll as an ambulatory surgical center (ASC) with Minnesota Health Care Programs (MHCP), an ASC must be certified by Medicare as a free-standing ambulatory surgical center. The certification is done by the Minnesota Department of Health (MDH) or the health department in the state in which it is located.

How to Enroll

Providers who wish to enroll with MHCP can do so in one of the following two ways.

Use the Online Minnesota Provider Screening and Enrollment (MPSE) Portal

· Register to access the MPSE portal by using the instructions under the Registration and Access section in the MPSE User Manual.

· If enrolling through the MPSE portal, you will be required to complete the following items and upload them into MPSE:

· Completed, signed and initialed copy of the Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) or MCO In-Network Provider Agreement (DHS-8355)

· Centers for Medicare & Medicaid Services (CMS) Ambulatory Surgical Center approval letter

· Confirmation of the MHCP provider screening fee payment or proof the fee was paid to another state or Medicare

· Clinical Laboratory Improvement Amendments (CLIA) certification (if applicable)

or

Fax Completed Forms to 651-431-7462

· Complete the following documents 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

· Enrollment forms:

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

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

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

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional) if the organization is a pay-to provider and enrolled as a fee-for-service provider

· CMS Ambulatory Surgical Center approval letter

· CLIA certification (if applicable)

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 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 (R letter to your MN–ITS mailbox or U.S. Postal Service telling you what we need or what you need to do to complete your enrollment.

Revalidation

MHCP is required to follow the 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 Enrollment with MHCP section of the MHCP Provider Manual for details.

You should notify MHCP of any changes in ownership at least 30 days before they occur. Changes in ownership require new copies of all enrollment documents along with a copy of the Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF).

Legal References

Minnesota Statutes, 144.50, subdivision 2 (Hospitals, Licenses; Definitions. Hospital, sanitarium, other institution; definition)
Minnesota Rules, 9505.0240, subpart 1 (ASC. Definition)
Minnesota Rules, 5221.0100, subpart 1a (Definitions. ASC)
Minnesota Rules, 4675.0100, subpart 8 (Definitions. Outpatient surgical center, center)
Code of Federal Regulations, title 42, section 440.60 (Definitions Medical or other remedial care provided by licensed practitioners)