Podiatrist Enrollment Criteria and Forms

Revised: November 1, 2023

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

Podiatrist Enrollment Criteria

To enroll as a podiatrist with MHCP, the podiatrist must be licensed by the Minnesota Board of Podiatric Medicine or current state of practice.

Podiatrists 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:

· 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 podiatry license

or

· Complete the following documents required to enroll as your provider type and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Individual – Provider Enrollment Application (DHS-4016) (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 podiatry license

· The EFT Vendor Number Notification (DHS-3725) (PDF) (optional) if you are the pay-to provider

Podiatry Clinic Enrollment Criteria

To enroll as a podiatry clinic with MHCP, the clinic must employ at least two MHCP-enrolled podiatrists.

Podiatry clinics who wish 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 FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO In-Network Provider Agreement (DHS-8355) (PDF)

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

or

· Complete the following documents required to enroll as your provider type 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 the MCO In-Network Provider Agreement (DHS-8355) (PDF)

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

· The EFT Vendor Number Notification (DHS-3725) (PDF) (optional) if the podiatry clinic is the 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 to complete your enrollment, we will send a request for more information letter via your MN-ITS mailbox or U.S. Postal Service 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.

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 Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 153.16 (Podiatry; Licensure)
Minnesota Rules, 9505.0175 (Definitions)