Physician Assistant Enrollment Criteria and Forms

Revised: October 30, 2023

To enroll as physician assistant with Minnesota Health Care Programs (MHCP), the physician assistant must be licensed by the Minnesota Board of Medical Practice or the state of practice.

How to Enroll

Physician assistant providers who wish to enroll with MHCP 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 documents in the MPSE portal:

· 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)

· A current license from the Minnesota Board of Medical Practice.

Exception: MHCP will allow an out-of-state license to practice in Minnesota if the provider is practicing for an Indian Health Service tribe.

or

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

· 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)

· A current license from the Minnesota Board of Medical Practice.

Exception: MHCP will allow an out-of-state license to practice in Minnesota if the provider is practicing for an Indian Health Service tribe.

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

We process forms in order by the 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 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 report any changes made on a provider record to MHCP Provider Eligibility and Compliance. Refer to the Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 147A.01, subdivision 18 (Physician assistant or licensed physician assistant)