Electronic Data Interchange (EDI) Trading Partner Enrollment Criteria and Forms

Revised: January 4, 2021

To enroll as a billing organization with Minnesota Health Care Programs (MHCP), the entity must be one of the following:

· Billing agent (28)

· Billing intermediary (98)

· Clearinghouse (95)

· Consolidated billing entity (28)

· Eligibility verification vendor (28)

· Health care data trading partner (28)

· Medicare carrier (28)

How to Enroll

Billing organizations 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

or

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

If enrolling by fax, the entity must complete and submit the following forms:

· Billing Intermediary, Clearinghouse and EDI Trading Partner Enrollment Application (DHS-4049) (PDF)

· Provider Setup Form (DHS-4087) (PDF)

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

Forms are processed 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 (RFMI) letter via your MN–ITS mailbox or U.S. mail telling you what we need or what you need to do to complete your enrollment.