Family Planning Agency Enrollment Criteria and Forms

Revised: July 13, 2020

To enroll as a family planning agency with Minnesota Health Care Programs (MHCP), the agency must have a medical director and provide family planning services under the direction of an MHCP-enrolled physician. The application must list the enrolled physician, and the medical director must sign the agency application and provider agreement.

How to Enroll

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)

· Individual Provider Affiliations (DHS-7329) (PDF)

· Copy of Clinical Lab Improvement Amendment (CLIA) certification (if lab services will be performed and billed)

or

· Complete the following documents required to enroll as a family planning agency 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)

Optional:

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

· Copy of CLIA certification (optional, required to bill for lab services)

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 (RFMI) letter via your MN–ITS mailbox or U.S. mail 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 the Revalidation section on the Provider Screening Requirements page of the MHCP Provider Manual for more information.

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.

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, 145.925, subdivisions 1a and 7 (Family Planning Grants: Family planning services; defined and Family planning services; information required)
Minnesota Rules, 9505.0280 (Family Planning Services)
Code of Federal Regulations, title 42, section 440.40 (Nursing facility services for individuals age 21 or older [other than services in an institution for mental disease], EPSDT, and family planning services and supplies)