Licensed Psychologist Enrollment Criteria and Forms

Revised: February 9, 2024

A psychologist must be licensed as a licensed psychologist (LP) by the Minnesota Board of Psychology or the state of practice to enroll as an LP with Minnesota Health Care Programs (MHCP).

MHCP will enroll LPs who are also qualified as licensed independent clinical social workers (LICSWs) or licensed marriage and family therapists (LMFTs).

LPs also qualified as clinical nurse specialists for mental health (CNS-MH) may request to enroll as an LP and CNS-MH, but they must provide services in both professional capacities and practice at two different locations.

How to Enroll

LP providers 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:

· Copy of current license

· Documentation supporting neuropsychology specialty, if applicable

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

or

Submit Forms via Fax

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

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

· Individual Provider Enrollment Application (DHS-4016) (PDF)

· Copy of current license

· Documentation supporting neuropsychology specialty, if applicable

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 you what you need to do to complete your enrollment.

Neuropsychology Post-Doctoral Sub-Specialty Enrollment

To enroll with MHCP as an LP with a neuropsychological specialty, the neuropsychologist must meet the following requirements:

· Have a diploma from one of the following boards or academies:

· American Board of Clinical Neuropsychology (ABCN)

· American Board of Professional Neuropsychology (ABPN)

· American Board of Pediatric Neuropsychology (ABPdN); or

· Neuropsychologists who do not have a diploma from one of the listed Boards are required to submit a copy of their certification from an American Psychological Association (APA)-approved Lesson C Internship.

· Be licensed or credentialed by another state’s board of psychology examiners in the specialty of neuropsychology using requirements equivalent to requirements specified by one of the boards previously referenced or

· Enrolled as an eligible provider with neuropsychology specialty before Dec. 31, 2010

Medicare Enrollment Denials

If Medicare denies enrollment as a Medicare provider, submit the Mental Health Professional Applicant Assurance Statement - Medicare Enrollment Denial (DHS-3864) (PDF) to MHCP Provider Eligibility and Compliance and again at revalidation. Inform MHCP Provider Eligibility and Compliance immediately when Medicare approves 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.

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 Enrollment. Refer to the Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 148.89 (Definitions)
Minnesota Rules, 7200.0100 (Definitions)
Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)