Indian Health Service (IHS) Enrollment Criteria and Forms

Revised: July 21, 2021

Indian Health Service (IHS) facilities and tribal facilities that are not IHS facilities, but have a P.L. 93-638 contract or agreement with an IHS office, can enroll as IHS facilities with Minnesota Health Care Programs (MHCP).

How to Enroll

Providers who wish to enroll with MHCP as an IHS facility 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)

· Copy of the P.L. 93-638 contract or agreement with an HIS

or

· Complete the following documents required to enroll as an IHS 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 of an Entity (DHS-5259) (PDF)

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

· Copy of the P.L. 93-638 contract or agreement with an IHS

If you provide substance use disorder treatment services, also include the following:

· Residential or Inpatient Behavioral Health Fund Service Request (DHS-6381) (PDF)

· Outpatient Behavioral Health Fund Service Request (DHS-6382) (PDF)

· Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491) (PDF)

· Copy of SUD license issued by the tribe or DHS

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

· Proof that the program is covered by general liability insurance in the amount of $2 million for each occurrence with DHS listed as the certificate holder at the following address:

DHS Provider Eligibility and Compliance
PO Box 64987
St Paul, MN 55164

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 notice or letter telling you what we need or 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.

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.02, subdivision 7 (Definitions; Vendor of medical care)
Minnesota Statutes, 256B.84 (American Indian Contracting Provisions)