Optometrist Enrollment Criteria and Forms

Revised: November 29, 2023

Optometrists must be licensed by the Minnesota Board of Optometry or the state where the practice is located to enroll as an optometrist with Minnesota Health Care Programs (MHCP).

How to Enroll

Optometrists who want to enroll with MHCP or make enrollment requests 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. You are required to upload the following:

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

· A copy of your optometry license

or

Submit Forms via Fax

Complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Individual – Provider Enrollment Application (DHS-4016) (PDF) or the 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 the MCO In-Network Provider Agreement (DHS-8355) (PDF)

· A copy of your optometry license

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

We process forms in order of date received. Whether enrolling or revalidating 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. Postal Service (or your MN–ITS mailbox, if you have an account) explaining 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.

MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all required forms and documents listed under How to Enroll to Provider Eligibility and Compliance at 651-431-7462.

We recommend using the MPSE portal and following the instructions in the Revalidation section of the MPSE user manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original Welcome Letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome Letter.

Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.

Reporting Changes

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

Legal References

Minnesota Statutes, 148.52 – 148.62 (Optometrists)
Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)