County Human Services Agency Enrollment Criteria and Forms

Revised: January 12, 2024

All Minnesota county human services agencies are currently enrolled as a human services agency. Tribal nations or newly established counties may also enroll as a county human services agency if they act in a similar capacity.

How to Enroll

To enroll in Minnesota Health Care Programs (MHCP) as a county or tribal human services agency, or make enrollment requests, the county or tribal human services agency 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:

· Provider Agreement (DHS-4138) (PDF)

or

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

· Organization – Provider Enrollment Application (DHS-4016A) (PDF).

· Provider Agreement (DHS-4138) (PDF)

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

· Home and Community-Based Services (HCBS) Programs Service Request (DHS-6638) (PDF) (Must submit to provide HCBS)

· EFT Vendor Number Notification (DHS-3725) (PDF) (optional)

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. mail telling you what you need to do to complete your enrollment.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services (CMS) federal provider screening regulations.

Review the Revalidation and Application Fees subsections in the Provider Screening Requirements section of the MHCP Provider Manual for more information about how to complete your revalidation and how to pay the application fee.

Submit the required information via the MPSE Portal or fax the following listed forms and credentials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Organization – Provider Enrollment Application (DHS-4016A) (PDF).

· Provider Agreement (DHS-4138) (PDF)

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

· EFT Vendor Number Notification (DHS-3725) (PDF)

A recording of the training provided to county human services agencies on Dec. 13, 2023, reviewing instructions to complete revalidation using the MPSE portal, is available. You can access the video using the following link: Revalidation Training Recording.

Note that the revalidation training recording does not include captions. If you need captions, please use the live captions feature offered by Google Chrome or another similar live captioning service. Find instructions for using live captions with Google Chrome on the live caption feature in Google Chrome.

Reporting Changes

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

Additional Resources

Minnesota Statutes, 256B.04, subdivision 21 (Provider Enrollment)
Minnesota Statutes, 256B.04, subdivision 22 (Application Fee)