Rural Health Clinic Enrollment Criteria and Forms

Revised: January 10, 2023

To enroll as a rural health clinic (RHC) with Minnesota Health Care Programs (MHCP), the RHC must have an approval letter from the Centers for Medicare & Medicaid Services (CMS).

Enrollment Criteria

RHC 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 Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) (DHS-3903) (PDF)

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

· Copy of the site’s CMS approval letter or 330 HRSA Grant

or

· Complete the following documents required to enroll as an RHC 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)

· Alternative Payment Methodology Election for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) (DHS-3903) (PDF)

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

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

· Copy of the site’s CMS approval letter or 330 HRSA Grant

If the RHC wants to add a category of service to an existing provider record, the RHC must complete and submit PPS Rate Adjustment for Scope of Service Change (DHS-4561) (PDF) via fax or MPSE.

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 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. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes 256B.0625, subdivision 30 (Covered Services; Other clinic services)
Minnesota Rules 9505.0395, subpart 1 (Rural Health Clinic Services and Federally Qualified Health Center Services; Definition)
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 4, section 440.20 (Requirements and Limits Applicable to All Services; Outpatient hospital services and rural health clinic services)