Adult Day Treatment Enrollment Criteria and Forms

Revised: December 7, 2023

To enroll as an adult day treatment provider with Minnesota Health Care Programs (MHCP), the entity must meet one of the following requirements:

· Be a community mental health center

· Be an outpatient hospital

· Have a county contract to provide day treatment

How to Enroll

Adult day treatment providers who want to enroll with MHCP or make changes to their enrollment 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 using the MPSE portal for enrollment, the Organization – Provider Enrollment Application (DHS-4016A) (PDF) does not need to be completed. The following items need to be completed and uploaded into MPSE:

· Completed, signed, and initialed Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF)

· MHCP provider screening fee payment confirmation or proof the fee was paid to another state or Medicare

· County contract

· An ADT approval letter from the Adult Mental Health Division

Video modules and webinar trainings for learning how to use the MPSE portal can be found on the MPSE portal training site.

or

Submit Forms via Fax

Complete and fax the following enrollment forms and required documents to MHCP Provider Eligibility and Compliance at 651-431-7462.

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

· Completed, signed, and initialed Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF)

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

· EFT Supplier ID Notification (DHS-3725) (PDF) (Optional)

· Adult Day Treatment Contract Cover Sheet (DHS-3868)

· MHCP provider screening fee payment confirmation or proof the fee was paid to another state or Medicare

· County contract

· An ADT approval letter from the Adult Mental Health Division

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 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.

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

Legal References

Minnesota Statutes 245.462, subdivision 8 (Definitions; Day treatment services)
Minnesota Statutes 245.4712 (Community Support and Day Treatment Services)
Minnesota Rules 9535.4056 (Day Treatment Services)
Code of Federal Regulations, title 42, section 440.40 (Nursing facility services for individuals age 21 or older [other than services in an institution for mental disease], EPSDT, and family planning services and supplies)
Code of Federal Regulations, title 42, section 440.130 (Diagnostic, screening, preventive, and rehabilitative services)