Public Health Nursing Clinic (PHNC) Enrollment Criteria and Forms

Revised: January 26, 2021

To enroll as a Public Health Nursing Clinic (PHNC) with Minnesota Health Care Programs (MHCP), a PHNC must be one of the following:

· Government entities such as a county, city, or school district.

· Non-governmental entities performing service(s) on behalf of the County.

Enrollment Requirements:

· Providers must obtain or have a National Provider Identifier (NPI).

· Must pay the application fee.

· Non-governmental entities must submit a copy of a county contract to provide the service on behalf of the County.

· If the provider chose to perform any services that require a comprehensive Home Care license, they must submit a copy of the license.

· If the service(s) requires Medicare certification, they must submit a copy of the Medicare certification or letter and a copy of the comprehensive home care license.

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)

· All required documents associated with the requested service(s)

· A copy of county contract for non-governmental entity

or

· Complete the following documents required to enroll as a PHNC 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)

Note: only disclose management employee(s), director or authorizing agent who oversees the day-to-day operations

· All required documents associated with the requested service(s)

· A copy of county contract for non-governmental entity

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 your MN–ITS mailbox (if you have a MN–ITS 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

You must notify MHCP any time a change occurs. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statute 256B.04, subdivisions 21–22 (Provider enrollment and Application fee)