Medical Services Group Enrollment Criteria and Forms

Revised: January 31, 2024

To enroll as a billing entity for a physician group 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:

· Acupuncturist

· Chiropractor

· Dentist

· Nurse Practitioner

· Physician

· Physician Assistant

· Podiatrist

How to Enroll

Physician group billing entities who wish to enroll with MHCP can do so in one of the following ways.

Online Minnesota Provider Screening and Enrollment (MPSE) Portal

Register to access the Minnesota Provider Screening and Enrollment portal by using the instructions under the Registration and Access section in the MPSE User Manual and complete your enrollment online using the MPSE portal. If enrolling through the MPSE portal, you will be required to upload a:

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

· Copy of the Individual Provider Affiliations (DHS-7329) (PDF) listing the individual providers who are affiliated with your organization.

or

Submit Forms via Fax

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)

· 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 (DHS-5259) (PDF)

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional) if the organization is a pay-to provider and enrolled as a fee-for-service provider.

Review and keep a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF).

We process forms in date order 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. 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 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.

Legal References

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