Dentists and Dental Group Enrollment Criteria and Forms

Revised: October 18, 2023

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

Enrollment Criteria

Providers wanting to enroll with MHCP or make enrollment requests can do so in one of the following 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:

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

· Verification of current dental license

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

Dentist

To enroll as an individual dentist with MHCP, a dentist must be licensed by the Minnesota Board of Dentistry or Board of Dentistry in the state of practice.

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

· Verification of current dental license

· Enrollment forms:

· Individual – Provider Enrollment Application (DHS-4016) (PDF)

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

· Include the electronic funds transfer (EFT Supplier ID Notification (DHS-3725) (PDF) if the dentist is a pay-to provider

Dental Group

If enrolling by fax, the dental group must complete and submit the following:

· Enrollment forms:

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

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

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

· Include the EFT Supplier ID Notification (DHS-3725) (PDF) if the dental group is a pay-to provider

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, we will send a request for more information letter to your MN–ITS mailbox or through U.S. Postal Service telling you what you need to do to complete your enrollment.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services final federal provider screening regulations.

Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for more information on completing your revalidation.

Reporting Changes

Report any changes made on a record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment in Enroll with MHCP under Provider Basics in the MHCP Provider Manual for details.

Legal References

Minnesota Statutes, 150A.06 (Licensure)
Minnesota Rules, 9505.0175 (Definitions)
Minnesota Statutes, 9505.0195 (Provider Participation)
Minnesota Statutes, 9505.0270 (Dental 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 440.100 (Dental services)