Audiologist Enrollment Criteria and Forms

Revised: August 17, 2023

To enroll with Minnesota Health Care Programs (MHCP), audiologists must comply with the requirements of Minnesota Rules and must first enroll with Medicare per Minnesota Rules 9505.0391.

A person is eligible to enroll as an audiologist with MHCP if he or she maintains state licensure and completes registration requirements. If the state does not license providers of audiology services, the applicant for enrollment with MHCP must demonstrate that he or she either holds a Certificate of Clinical Compliance in Audiology (CCC-A) from the American Speech-Language-Hearing Association (ASHA) or meets the following clinical practicum standards:

· Doctoral degree with an emphasis in audiology, or its equivalent as determined by the commissioner, from an accredited educational institution,

· Clinical experience as required by ASHA, the American Board of Audiology or an equivalent as determined by the commissioner,

· Pass the national examination in audiology.

Audiologists who wish to be affiliated with a rehabilitation billing entity must enroll with MHCP.

How to Enroll

Audiologists 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 audiologist license and registration from the Minnesota Department of Health (MDH)

· Copy of current ASHA certification

· 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.

· 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 current ASHA certification

· Copy of current audiologist license and registration with the MDH

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 the 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, 148.511-148.5198 (Speech-language Pathologists and Audiologists)
Minnesota Statutes, 256B.0625, subdivision 8b (Covered Services, Speech language pathology and audiology services)
Minnesota Rules, 9505.0391 (Therapists Eligible to Enroll as Providers)
Code of Federal Regulations, title 42, section 440.110 (Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders)