Optical Company Enrollment Criteria and Forms

Revised: March 10, 2026

An optical company must employ at least one Optometrist currently enrolled with Minnesota Health Care Programs (MHCP) to enroll as an optical company with MHCP.

How to Enroll

Optical companies who want to enroll with MHCP can do so in one of the following ways.

Online Minnesota Provider Screening and Enrollment (MPSE) Portal

Register to access the Minnesota Provider Screening and Enrollment portal by using the instructions under the Registration and Access section in the MPSE User Manual and complete your enrollment online using the MPSE portal. If enrolling through the MPSE portal, you will be required to upload the following:

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

· Copy of the Individual Provider Affiliations (DHS-7329) (PDF) listing the individual providers who are affiliated with your organization.

or

Submit Forms via Fax

Complete the following documents and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

· 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 MCO In-Network Provider Agreement (DHS-8355) (PDF)

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

· EFT Supplier ID Notification (DHS-3725) (PDF) (optional) if the organization is a pay-to provider and enrolled as a fee-for-service provider.

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

We process forms in date order 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 telling you what you need to do to complete your enrollment.

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 listed under How to Enroll to Provider Eligibility and Compliance at 651-431-7462. We recommend using the MPSE portal and following the instructions in the Revalidation section of the MPSE user manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original Welcome Letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome Letter.

Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, 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 in the Enrollment with Minnesota Health Care Programs (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, a new screening fee payment, along with a signed copy of the Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF).

Legal References

Code of Federal Regulations, title 42, section 440.60 (Medical or other remedial care provided by licensed practitioners)