Chiropractor Enrollment Criteria and Forms

Revised: August 15, 2023

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

How to Enroll

Providers 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:

· Copy of current chiropractor license from the Minnesota Board of Chiropractic Examiners, or another state

· 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)

or

Submit Forms via Fax

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

Chiropractor

Individual chiropractors must be licensed as a chiropractor.

· 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 Managed Care Organization In-network Provider Agreement (DHS-8355) (PDF)

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional) if the individual is a pay-to provider and enrolled as a fee-for-service provider

· Copy of chiropractor license from the Minnesota Board of Chiropractic Examiners, or another state

Chiropractor Group

To enroll as a chiropractic group, the chiropractic group must be composed of at least one enrolled chiropractor.

· 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)

· EFT Vendor Number Notification (DHS-3725) (PDF) (optional) if the group is a pay-to provider and enrolled as a fee-for-service provider.

· Copy of chiropractor licenses from the Minnesota Board of Chiropractic Examiners

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 telling you 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 Enrollment with Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 148.01 (Chiropractic)
Minnesota Rules, 2500.0550 (Professional Designations)
Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)