Pharmacy and Pharmacist Enrollment Criteria and Forms

Revised: January 16, 2024

Pharmacies and individual pharmacists may enroll with Minnesota Health Care Programs (MHCP).

Enrollment Criteria

The dispensing prescription drug provider must meet at least one of the following criteria to enroll as a pharmacy or individual pharmacist with MHCP:

· Be licensed by the Minnesota Board of Pharmacy

· Be licensed by the state in which they practice

· If out-of-state and planning to ship prescription drugs into Minnesota, be licensed in the state of practice and Minnesota

· If dispensing prescription drugs in a local trade area where no MHCP-enrolled pharmacy exists, a physician must personally dispense the prescribed drug according to applicable Minnesota statutes and adhere to the labeling requirements of the Minnesota Board of Pharmacy

· Be a physician or nurse practitioner employed by, or under contract with, a community health board for communicable disease control

How to Enroll as a Pharmacy

Providers can enroll with MHCP, or make enrollment requests, in one of the following ways.

· Use the Minnesota Provider Screening and Enrollment (MPSE) portal by following the Registration Instructions.

· 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)

or

· Complete the following documents required to enroll for your specific provider type and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Enrollment forms:

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

· Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF)

· EFT Supplier ID Notification (DHS-3725) (PDF) (Optional)

· Copy of pharmacy license

· If applicable, include any of the following:

· Minnesota non-resident pharmacy license

· Limited service pharmacy license from the Board of Pharmacy

· MHCP provider screening fee payment confirmation or proof the fee was paid to another state or Medicare

· Home Infusion Pharmacy Applicant Assurance Statement (DHS-5947) (PDF)

· Medication Therapy Management Services (MTMS) Privacy/Space Requirements (DHS-6206) (PDF)

Pharmacies licensed separately, but under the same federal employer identification number (FEIN) as another provider type (such as a hospital with an inpatient pharmacy and a separately licensed retail pharmacy located within the same hospital), must enroll separately.

How to Enroll as an Individual Pharmacist

Providers can enroll with MHCP, or make enrollment requests, in one of the following two ways.

· Use the Minnesota Provider Screening and Enrollment (MPSE) portal by following the Registration Instructions.

· Upload the following documents in the MPSE portal:

· Individual Non-Pay-To Provider Agreement (DHS-4611A) (PDF) or the MCO In-Network Provider Agreement (DHS-8355) (PDF)

or

· Complete the following documents required to enroll for your specific provider type and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· Enrollment forms:

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

· Individual Non-Pay-To Provider Agreement (DHS-4611A) (PDF) or the MCO In-Network Provider Agreement (DHS-8355) (PDF)

· Copy of the license from the Minnesota Board of Pharmacy or other documentation as appropriate

· Copy of either diploma

· Copy of the DHS approved Council of Pharmacy Education program course completion certificate

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

We process forms in date order received. Allow 30 days for processing whether enrolling using the MPSE portal or by fax. We will send a request for more information letter through U.S. Postal Service (or in your MN–ITS mailbox, if you have an account) telling you what you need to do to complete your enrollment if we need more information.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services final federal provider screening regulations.

MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all required forms and documents to the Minnesota Department of Human Services.

Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, about the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.

Reporting Changes

Report any changes made on a provider record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment on the Enroll with Minnesota Health Care Program (MHCP) section webpage of the MHCP Provider Manual for details.

Changes that occur prior to notifying MHCP or missing or incorrect information may result in billing suspension. Minnesota Statutes, 256B.04, subdivision 21(d).

Additional Resources

Minnesota Statutes, 151.01 (Pharmacy; Definitions)
Minnesota Statutes, 256B.0625, subdivision 13 (Drugs)
Minnesota Rules, 6800.0100 (Board of Pharmacy; Definitions)
Minnesota Rules, 6800.2400 (Pharmacist-In-Charge)
Code of Federal Regulations, title 42, section 440.120 (Prescribed drugs, dentures, prosthetic devices, and eyeglasses)