Independent Diagnostic Testing Facility Enrollment Criteria and Forms

Revised: September 10, 2020

To enroll as an independent diagnostic testing facility with Minnesota Health Care Programs (MHCP), the facility must be independent of a hospital or physician clinic in which diagnostic tests are performed by licensed, certified non-physician personnel under appropriate physician supervision. The facility may be one of the following:

· Fixed location

· Mobile entity

How to Enroll

Independent diagnostic testing facilities 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. Also, upload the following in the MPSE Portal:

· Provider Agreement (DHS-4138) (PDF)

· Advanced Diagnostic Imaging Assurance Statement (DHS-3872) (if applicable)

· Accreditations for Advanced Diagnostic Imaging

· Off-site approval letter from Medicare

· Confirmation of fee payment to MHCP, another state, or Medicare

· Complete the following documents required to enroll as an independent diagnostic testing facility and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

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

· Provider Agreement (DHS-4138) (PDF)

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

· EFT Vendor Number Notification (DHS-3725) (PDF) (optional)

· Advanced Diagnostic Imaging Assurance Statement (DHS-3872) (if applicable)

· Accreditations for Advanced Diagnostic Imaging (if applicable)

· Off-site approval letter from Medicare

· Confirmation of fee payment to MHCP, another state, or Medicare

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 letter via U.S. mail (or in your MN–ITS mailbox, if you have an account) telling you what we need or 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 record to MHCP Provider Enrollment. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Changes in ownership should be reported 30 days in advance, and require new copies of all enrollment documents, along with a signed copy of the Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF).

Additional Resources

Minnesota Statutes, 144.12, subdivision 1 (Regulation, Enforcement, Licenses, Fees; Rules)
Minnesota Statutes, 256B.02, subdivision 7 (Definitions; Vendor of medical care)
Minnesota Statutes, 256B.0625 (Covered Services)
Minnesota Statutes, 144.1205 (Radioactive Material; Special Nuclear Material)
Minnesota Rules, 9505.0305 (Laboratory and X-ray Services)
Code of Federal Regulations, title 42, section 440.130 (Diagnostic, screening, preventive, and rehabilitative services)