Nurse Practitioner Enrollment Criteria and Forms

Revised: October 31, 2023

Nurse practitioners may enroll with Minnesota Health Care Programs (MHCP) as individuals or groups.

Enrollment Criteria

Providers who wish to enroll with MHCP as a nurse practitioner (NP) or make enrollment requests can do so in one of the following 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:

· Copy of current NP national certification from the Pediatric Nursing Certification Board, American Nurses Credentialing Center, American Academy of Nurse Practitioners, or other national nurse certification organization

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO In-Network Provider Agreement (DHS-8355) (PDF)

· Copy of Certified Nurse Practitioner license (if outside of Minnesota)

or

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

· Copy of current NP national certification from the Pediatric Nursing Certification Board, American Nurses Credentialing Center, American Academy of Nurse Practitioners, or other national nurse certification organization

· Copy of Certified Nurse Practitioner license (if outside of Minnesota)

· Enrollment forms:

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

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO In-Network Provider Agreement (DHS-8355) (PDF)

· EFT Supplier ID Notification (DHS-3725) (PDF) if the individual NP is a pay-to provider

Review and keep a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF).

We process forms in the 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 notice or letter 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 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 record to MHCP Provider Enrollment. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 148.171 (Nurses; Definitions; Title)