Allied Oral Health Professional and Allied Oral Health Professional Group Enrollment Criteria and Forms

Revised: August 29, 2024

Allied Oral Health Professional Group

Allied oral health professional group bills on the behalf of a dental therapist (DT), advanced dental therapist (ADT), and / or a collaborative practice dental hygienist (CPDH).

An MHCP-enrolled allied oral health professional group may be one of the following:

· Military and veterans administration hospital, clinic, or care setting

· Oral health educational institution

· Clinic or practice setting, including mobile dental unit, in which at least 50 percent of the total patient base of the DT or ADT:

· Are enrolled in MHCP

· Have a medical disability or chronic condition that creates a significant barrier to receiving dental care

· Do not have dental coverage and have a gross family income at or below 200 percent of the federal poverty guidelines (FPG)

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.

· When selecting the enrollment record type in MPSE, select Dental Hygienist Group - 31-O.

· If enrolling using the MPSE portal, upload the following items in the MPSE portal:

· Completed Individual Provider Affiliations (DHS-7329) (PDF).

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

or

· Complete the following documents required to enroll and fax your materials to MHCP at 651-431-7462.

· Enrollment forms:

· Organization Provider Enrollment Application (DHS-4016A) (PDF) (select provider type 31 in the left column)

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

· Individual Provider Affiliations (DHS-7329)

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

Allied Oral Health Professional - Individual

Individual DT, ADT, or CPDH providers enroll directly with MHCP and must meet the following requirements:

· Be licensed by the Board of Dentistry in the state in which they practice

· In addition, ADT’s must be certified by the Minnesota Board of Dentistry

· Have entered into a board-approved collaborative agreement or collaborative management agreement (as applicable) with a licensed dentist

· Be employed by an MHCP-enrolled group

· Have an individual national provider identifier (NPI) number

An Allied Oral Health Professional can be one of the following:

· critical access dental provider

· dental therapist (DT)

· advanced dental therapist (ADT)

· or a collaborative practice dental hygienist (CPDH).

How to Enroll

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

· Providers enrolling themselves can register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal.

· Organizations enrolling individual allied oral health professionals on their behalf can use the Organization to Individual Affiliations instructions to complete the enrollment using the MPSE portal.

· If enrolling using the MPSE portal, upload the following items in the MPSE portal:

· Copy of current license and certification (if applicable) from the Minnesota Board of Dentistry

· Copy of current ADT certificate from the Minnesota Board of Dentistry (ADT only)

· Copy of DT certificate from the Board of Dentistry

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

or

· Complete the following documents required to enroll and fax your materials to MHCP at 651-431-7462.

· Enrollment forms:

· Individual Provider Enrollment Application (DHS-4016) (PDF) (select provider type 31 in the left column)

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

· Collaborative Practice Dental Hygienist Assurance Statement (DHS-6025) (PDF) – for CPDH only

· Copy of current license from the Board of Dentistry

· Copy of current ADT certificate from Board of Dentistry

If you are dually licensed as an advanced dental therapist or dental therapist and a dental hygienist, this information must be included on your enrollment application. Copies of both license types must be submitted with your enrollment application.

DTs who subsequently become certified as ADTs must update their MHCP provider enrollment. Fax or upload via the MPSE portal the following to MHCP:

· Cover letter indicating completion of the requirements for ADT certification

· Board certificate

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 (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. Review the Request Submitted and Next Steps section of the MPSE user manual for information on request statuses and outcomes in the MPSE portal.

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. Instructions for completing revalidation using the MPSE portal can be found on the Revalidation section of the MPSE User Manual.

Reporting Changes

Report any changes made on a record to MHCP. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Legal References

Minnesota Statutes, 150A.105 (Dental Therapist)
Minnesota Statutes, 150.106 (Advanced Dental Therapist)
Minnesota Statutes, 150A.10 (Allied Dental Personnel)
Minnesota Statutes, 150A.10, subdivision 1a (Collaborative practice authorization for dental hygienists in community settings)
Code of Federal Regulations, title 42, section 440.100 (Dental services)