Federally Qualified Health Center (FQHC) Enrollment Criteria and Forms

Revised: September 8, 2021

To enroll as a federally qualified health center (FQHC) with Minnesota Health Care Programs (MHCP), the FQHC must be certified by the Centers for Medicare & Medicaid Services (CMS). Indian tribes may change to an FQHC classification if they have Public Law 93-638 status.

Enrollment Criteria

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)

· Alternative Payment Methodology Election for FQHCs and RHCs (DHS-3903) (PDF)

· CMS (Medicare) Approval Letter indicating facility has been approved as an FQHC, or a copy of the 330 HRSA Grant documents that include a list of sites covered by the grant and the grant effective dates (whichever is applicable)

· Tribes can include the cover page of their Public Law 93-638 status contract or compact with Indian Health Service (when applicable)

or

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

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

· Provider Agreement (DHS-4138) (PDF)

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

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

· Alternative Payment Methodology Election for FQHCs and RHCs (DHS-3903) (PDF)

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

· CMS (Medicare) Approval Letter indicating facility has been approved as an FQHC, or a copy of the330 HRSA Grant documents that include a list of sites covered by the grant and the grant effective dates (whichever is applicable).

· Tribes can include the cover page of their Public Law 93-638 status contract or compact with Indian Health Service (when applicable)

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 U.S. mail (or in your MN–ITS mailbox, if you have an account) telling you 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 Eligibility and Compliance (PEC). Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

If the FQHC wants to add a category of service to an existing provider record, the FQHC must complete and submit the PPS Rate Adjustment for Scope of Service Change (DHS-4561) (PDF) form by fax or by uploading it to the MPSE portal. Once received, PEC will forward this form to the Rates area for evaluation.

Changes in ownership should be reported 30 days in advance, and require new copies of all enrollment documents, along with a signed copy of the Provider Entity Sale or Transfer Addendum DHS-5550 (PDF).

Additional Resources

Minnesota Statutes, 256B.0625, subdivision 30 (Covered Services; Other clinic services)
Minnesota Statutes, 9505.0395 (Rural Health Clinic Services and Federally Qualified Health Center Services)

Code of Federal Regulations, title 42, section 405.2401 (Rural Health Clinic and Federally Qualified Health Center Services; Scope and definitions)
Code of Federal Regulations, title 42, section 491.2 (Rural Health Clinics: Conditions for Certification; and FQHCs Conditions for Coverage; Definitions)