Enrollment Record Information

Revised: January 19, 2024

Overview

On this page, you can add new enrollment record information or change existing information. This page contains fields for general information related to the enrollment record. Fields on this page may be different depending on the enrollment record type selected and whether the user is in an organization or individual provider.

Portfolio/Profile Information

See Portfolio/Profile Information on the Recurring Items page of the Minnesota Provider Screening and Enrollment (MPSE) User Manual.

Enrollment Record Information

This is a recurring section that appears on multiple MPSE pages for informational purposes only. See Enrollment Record Information on the Recurring Items page of the MPSE User Manual.

Enrollment Record Information

This section appears twice on this page, but in this second Enrollment Record Information section, you can view or change information specific to your enrollment record.

Do you wish to reinstate this enrollment record?

This field only appears when the enrollment record is in inactive or encounter only status. Select Yes to request to change the status to active status. Select No to keep the enrollment record in inactive or encounter only status.

Provider’s Practicing Name

Organizations:
Type your practice name in the Provider’s Practicing Name field. Your practice name must be entered in 50 characters or less. If your entire practice name cannot be entered in 50 characters or less, type up to the allowed amount; do not abbreviate. This can be either your legal business name or your doing business as name.

Individuals:
Type your full name (first, middle, last name) in the Practice Name field. Your practice name must be entered in 50 characters or less. If your entire practice name cannot be entered in 50 characters or less, type up to the allowed amount; do not abbreviate.

Unique Display Name

Type your unique display name in the Unique Display Name field. A unique display name is a unique name you can assign your enrollment record to help identify each of your enrollment records. For example, if you are an organization with multiple locations with the same practice name, you could use the unique display name ABC 1 for your first location and ABC 2 for your second location to help you quickly identify which enrollment record you are viewing.

Example for an individual: If you have multiple enrollment records because you are both a dentist and a physician, you could use Your Name DDS for your dentist enrollment record and Your Name MD for your physician enrollment record.

You can use any name you like as your unique display name to help you identify your different enrollment records, but you can only use a unique display name once. It cannot be on more than one enrollment record.

Is this enrollment record for your own private practice?

Select the Yes option if you are creating an individual enrollment record for your private practice. Select the No option if this is not for your own private practice.

This question only appears for individual providers.

List the legal name of your private practice that is associated to your federal tax ID number. If you maintain a private practice and have a Type 2 NPI that identifies the practice, you must also enroll your organization.

Type the legal name of your private practice in the List the legal name of your private practice field. Your practice name must be entered in 50 characters or less. If your entire practice name cannot be entered in 50 characters or less, type up to the allowed amount; do not abbreviate. This can be either your legal business name or your doing business as name.

If you have a Type 2 National Provider Identifier (NPI) for your private practice, you must enroll your private practice as an organization portfolio with your Type 2 NPI using the New Portfolio Request process. MHCP will make payments to the legal name of your practice. Therefore, use caution if you have not registered your name with the Office of the Minnesota Secretary of State to obtain documentation to be able to cash or deposit funds that are issued to you.

This field only appears if you select Yes to the question Is this enrollment record for your own private practice?

Enrollment Record Type

Use the drop-down list in the Enrollment Record Type field to select your enrollment record type. Find detailed enrollment requirements for each provider type in the Eligible Providers section of the MHCP Provider Manual.

Medicaid Agreement Indicator

This field is for office use only and is not able to be modified by providers.

Are you, or is this facility enrolled with Medicare?

Select Yes if you or the facility are enrolled with Medicare or No if you are not. If you select Yes, you must enter Medicare enrollment information on the Manage Medicare Enrollment Information page.

Encounter Indicator

Select an Encounter Indicator option that describes your enrollment record. The options are:

· Fee For Service and In-Network Managed Care: Fee-for-service (FFS) providers bill Medical Assistance (MA) directly for services provided to members on MA who are not enrolled with a managed care organization (MCO) or for services covered by MA but not by an MCO. In an FFS payment system, providers bill MA directly and receive reimbursement for each covered service. In-network managed care providers are providers who see MHCP members who are enrolled with an MCO and bill for those services through the MCO. Selecting this option allows providers to participate in the FFS payment system and bill MCOs that they are enrolled with.

· In-Network Managed Care Only: In-network managed care only is for providers who are enrolled with one or more MCOs and provide services to members who are enrolled with that MCO. Services provided to members through an MCO are billed through that MCO.

· Out-of-Network Managed Care Only: Out-of-network managed care only is for providers who rendered services to an MCO-enrolled MHCP member but are not enrolled with that MCO.

Remittance Sequence

Use the drop-down list in the Remittance Sequence field to select the sequence in which you would like to receive your remittance advice information. More information about remittance advice information can be found in the Remittance Advice section of the MHCP Provider Manual.

EFT Vendor Number

Type your electronic funds transfer (EFT) vendor number in the EFT Vendor Number field. Minnesota Management & Budget (MMB) assigns your vendor number to you and it must be active to receive payments for claims via EFT. Learn more about requesting an EFT vendor number on the Electronic Funds Transfer section of the MHCP Provider Manual.

This field is optional. If you choose to leave this field blank, claim payments will be distributed to the provider via paper check.

EFT Vendor Location Code

Type your EFT vendor location code in the EFT Vendor Location Code field. This is the three numbers listed after the dash of your EFT vendor number you received from MMB. This information is required if an EFT vendor number is present.

EFT Effective Date

Provider Eligibility and Compliance completes the EFT Effective Date field after they review and verify your vendor number. This field displays the effective date of your EFT vendor number with MHCP. This field is for DHS office use only and the provider cannot change the date in this field.

State Tax ID

Type your state tax ID in the State Tax ID field. A state tax ID is required if you have a portfolio type of organization, your profile identifier is a Federal Employer Identification number (FEIN), and your encounter indicator is not out-of-network managed care only. If the physical address is in Minnesota, your state tax ID must be seven digits.

ISD Number

Type your Independent School District Number (ISD) in the ISD Number field. There is a limit of five characters in this field. This field will only display if your selected enrollment record type is Individual Education Plan (IEP) - 09.

Complete Name of Regional Cooperative or Charter School

Type your regional cooperative or charter school name in the Complete Name of Regional Cooperative or Charter School field. This field will only display if your selected enrollment record type is Individual Education Plan (IEP) - 09.

Does your facility provide physical or occupational therapy to community residents?

Select Yes if your facility provides physical or occupational therapy to community residents or select No if your facility does not provide physical or occupational therapy to community residents. This field only displays if you selected enrollment record type Nursing Facility - 00.

Is this facility freestanding or is it in a hospital setting?

Select Freestanding Facility if your clinic is a freestanding facility. Select Hospital Setting if your clinic is in a hospital. This field will only display if your selected enrollment record type is Renal Dialysis Center – 04.

Is this facility a hospital-based clinic?

Select Yes if your facility is a hospital-based clinic or select No if your facility is not a hospital-based clinic. This field only displays if your selected enrollment record type is one of the following:

· 00-Nursing Facility

· 04-Renal Dialysis Center

· 22-Ambulatory Surgical Center

· 02-Hospice

· 60-Home Health

· 52-Federally Qualified Health Center

· 53-Rural Health Clinic

· 20-Physician Clinic

Associated Hospital Medicare ID Number

If you selected Yes to the “Is this facility a hospital-based clinic?” question, you will be required to type the Medicare ID of your associated hospital in the Associated Hospital Medicare ID Number field.

Phone Number

Type your 10-digit phone number in the Phone Number field. You are required to enter a phone number unless your provider type is direct support worker.

Fax Number

Type your 10-digit fax number in the Fax Number field.

Email Address

Type a valid email address in the Email Address field. Your email address must be formatted properly or it will be considered invalid. An example of a properly formatted email address is user@domain.com.

Risk Level

This field is for DHS office use only and the provider cannot changed information in this field. The Risk Level field will display your risk level once Provider Eligibility and Compliance reviews and processes your enrollment record request. Your risk level will be limited, moderate or high. Provider Eligibility and Compliance determines the level based on your enrollment record type and other factors. To review more information on risk levels, refer to the Risk Levels and Enrollment Verification Requirements section of the MHCP Provider Manual.

Fingerprint Background Study Documentation

The Fingerprint Background Study Documentation field shows your uploaded fingerprint-based background study document. Click the blue page icon next to this field to open a fingerprint-based background study that has been uploaded to this page.

Remove Upload
Check the Remove Upload box to remove the document that is currently uploaded. This will happen automatically if there is an existing document and you upload a new document.

Upload Fingerprint Background Study Documentation

Use the Upload Fingerprint Background Study Documentation field to upload your fingerprint-based background study documentation. Click on Upload Fingerprint Background Study Documentation or click on the icon shaped like an eye to open a dialogue box on your computer which will allow you to select a document to upload. MPSE only allows the following document types for upload: PDF, JPG, and PNG.

Tribal Information

In the Tribal Information section, you will provide information about you or your facility providing services to members of tribes in or outside of Minnesota. This section will not display for individuals with an enrollment record type of direct support worker.

Do you, or does this facility have a contract with a Minnesota tribe to provide services on tribal land?

Select Yes if you or your facility has a contract with a Minnesota tribe to provide services on tribal land. Select No if you or your facility does not have a contract with a Minnesota tribe to provide services on tribal land.

Do you, or does this facility have a contract with a tribe (other than Minnesota) to provide services on tribal land?

Select Yes if you or your facility has a contract with a non-Minnesota tribe to provide services on tribal land. Select No if you or your facility does not have a contract with a non-Minnesota tribe to provide services on tribal land.

Tribal Service Note

Use the Tribal Service Note field to add a note about your tribal information. If you answered Yes to having a contract with a non-Minnesota tribe, you are required to add a note. Your note must be 4,000 characters or less. Your note must include the following information:

· The state the tribe is located in

· The tribal name

· The service(s) and the date(s) the service(s) was or will be provided.

Termination Information

In the Termination Information section, you can terminate your enrollment with MHCP. By default, this section is collapsed. Refer to the Recurring Items page of the MPSE user manual for more information on collapsing and expanding sections within MPSE.

Terminate

To end your enrollment with MHCP, select the Terminate box. By default, the box is not checked. If you have entered a Termination Date, you must check this box.

Termination Date

Enter the date that you would like to end your enrollment with MHCP in the Termination Date field. You must enter a termination date if you checked the Termination check box.

Terminate Reason

Select the termination reason in the Termination Reason field. The options given are Location Closed, Voluntary Termination, Change of Ownership, and Other. You must select a termination reason if you checked the Termination check box.

Termination Other Description

If you selected Other for in the Termination Reason field, you must enter a description for your termination reason.

Continue

Click Continue to save your changes and go to the next page.

Cancel

Click Cancel to go back to the previous page.