Mental Health Group Enrollment Criteria and Forms

Revised: October 26, 2023

To enroll as a mental health group with Minnesota Health Care Programs (MHCP), the group must have at least one of the following enrolled MHCP providers affiliated:

· Clinical nurse specialist (CNS) in mental health

· Licensed independent clinical social worker (LICSW)

· Licensed marriage and family therapist (LMFT)

· Licensed professional clinical counselor (LPCC)

· Licensed psychologist (LP)

· Psychiatric nurse practitioner (NP)

· Psychiatry or osteopathic physician

· Mental health rehabilitative professional

· Tribal certified professionals

How to Enroll

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

Online MPSE Portal

Register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal. If enrolling through the MPSE portal, you will be required to upload a:

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

· For children’s therapeutic services and supports (CTSS) and adult rehabilitative mental health services (ARHMS): MHCP provider screening fee payment confirmation or proof the fee was paid to another state or Medicare

· Copy of CTSS or ARMHS certification letter

or

Submit Forms via Fax

Complete the following documents and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

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

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

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

· For children’s therapeutic services and supports (CTSS) and adult rehabilitative mental health services (ARHMS): MHCP provider screening fee payment confirmation or proof the fee was paid to another state or Medicare

· Copy of CTSS or ARMHS certification letter

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 the U.S. Postal Service (or your MN–ITS mailbox, if you have an account) telling you what you need to do to complete your enrollment.

We will conduct a site visit as part of the enrollment process when CTSS or ARMHS services are added. Please allow up to an additional 60 days for screening time. Refer to the Provider Screening Requirements webpage for more information.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services 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 Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual for details.

Additional Resources

Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)