Intensive Residential Treatment Services Enrollment Criteria and Forms

Revised: January 13, 2023

To enroll as an intensive residential treatment services (IRTS) provider with Minnesota Health Care Programs (MHCP), the provider must be a licensed Rule 36 facility.

How to Enroll

IRTS providers who wish to enroll with MHCP or make enrollment requests 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)

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

· Copy of Rule 36 license

· Copy of IRTS approval letter from Minnesota Department of Human Services (DHS) Behavioral Health Division

or

· Complete the following documents required to enroll as an IRTS provider and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Enrollment forms:

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

· Provider Agreement (DHS-4138) (PDF)

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

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

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

· Copy of Rule 36 license

· Copy of IRTS approval letter from DHS Behavioral 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 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 explaining 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 Enrollment. Refer to the Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes 256B.0622 (Intensive Residential Treatment Services)
Minnesota Statutes 245.461-486 (Adult Mental Health Act; Community Support and Day Treatment Services)