Psychiatric Residential Treatment Facility (PRTF) Enrollment Criteria and Forms

Posted: October 13, 2023

A PRTF provider that has been selected through the request for proposals must meet all of the following requirements to enroll with Minnesota Health Care Programs (MHCP) as a PRTF provider:

· Certified by Minnesota Department of Health as a PRTF and meet requirements for Board and Lodging or supervised living facilities (SLF) licensure.

· Licensed by Minnesota Department of Human Services

· Accredited by one of the following:

· Joint Commission

· Commission on Accreditation of Rehabilitation Facilities

· Council on Accreditation of Services for Families and Children

How to Enroll

Psychiatric Residential Treatment Facilities who wish to enroll with MHCP can do so in one of the follow two ways.

Online MPSE Portal

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 license as a Psychiatric Residential Treatment facility providing mental health services from the Minnesota Department of Human Services.

· Copy of current Minnesota Department of Health certification

· Completed, signed, and initialed 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)

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

or

Submit Forms via Fax

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

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

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

· Copy of current license as a Psychiatric Residential Treatment facility providing mental health services from the Minnesota Department of Human Services

· Copy of current Minnesota Department of Health certification

· Completed, signed, and initialed 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)

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

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 the 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.

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 provider record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment in the Enroll with 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, along with a signed copy of the Provider Entity Sale or Transfer Addendum DHS-5550 (PDF).