Rehabilitation Group Enrollment Criteria and Forms

Revised: June 21, 2024

To enroll as a rehabilitation billing entity with Minnesota Health Care Programs (MHCP), the billing entity must consist of at least two providers otherwise not eligible for a group provider number, in any combination of the following:

· Audiologist

· Hearing aid dispenser

· Occupational therapist (OT)

· Physical therapist (PT)

· Registered dietician or licensed nutritionist

· Speech-language pathologist (SLP)

How to Enroll

Rehabilitation billing entities who wish 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. Upload the following in the MPSE portal:

· 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)

· Individual Provider Affiliations (DHS-7329) (PDF)

or

Submit Forms via Fax

The billing entity must complete and sign the following documents required to enroll and fax the materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· 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 MCO In-Network Provider Agreement (DHS-8355) (PDF)

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

· 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 by the 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 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 in the How to Enroll section to DHS.

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, about 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.

Additional Resources

Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)