Community Health Clinic Enrollment Criteria and Forms

Revised: July 13, 2020

To enroll as a community health clinic (CHC) with Minnesota Health Care Programs (MHCP), a CHC must have a status of non-profit and tax exempt.

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)

· Applicant Assurance Statement – Community Health Clinic (DHS-5732) (PDF)

· Copy of article of incorporation (letter from the Secretary of State’s office) showing non-profit status

· Copy of letter from IRS showing tax-exempt status

· Copy of the clinic’s sliding fee schedule

or

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

· Enrollment forms:

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

· Provider Agreement (DHS-4138) (PDF)

· Disclosure of Ownership and Control Interest Statement for Participating Providers (DHS-5259) (PDF)

· Applicant Assurance Statement – Community Health Clinic (DHS-5732) (PDF)

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

· Copy of article of incorporation (letter from the Secretary of State’s office) showing non-profit status

· Copy of letter from IRS showing tax-exempt status

· Copy of the clinic’s sliding fee schedule

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. 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, 256B.0625 (Covered Services)
Minnesota Rules, 9505.0255 (Community Health Clinic Services)
Code of Federal Regulations, title 42, section 440.90 (Clinic services)