Owner/Authorized Persons
Revised: July 12, 2024
Manage Owner/Authorized Person Name
Portfolio/Profile Information
This is a recurring section that appears on multiple Minnesota Provider Screening and Enrollment (MPSE) pages for informational purposes only. See Portfolio/Profile Information on the Recurring Items page of the MPSE User Manual.
Owner/Authorized Person Name
The First Name, Middle Name, and Last Name fields cannot be modified after Minnesota Health Care Programs approves the owner or authorized person. You will know that the person has been screened and approved because the person’s name will be grayed out and you will not be able to edit the field.
To change the name of an owner or authorized person, add a note to the Profile Notes screen of the MPSE portal. The note must include documentation proving the name change.
First Name
Type the full first name of the owner or authorized person according to the IRS in the First Name field.
Middle Name
Type the full middle name of the owner or authorized person according to the IRS in the Middle Name field. This field is required if the Check if no Middle Name box is not checked.
Check if no Middle Name
Check this box if the owner or authorized person does not have a middle name. When the box is checked, the Middle Name field is disabled.
Last Name
Type the full last name of the owner or authorized person according to the IRS in the Last Name field.
Continue
Click Continue to save your changes and go to the next page.
Manage Owner/Authorized Person Detail
Portfolio/Profile Information
This is a recurring section that appears on multiple MPSE pages for informational purposes only. See Portfolio/Profile Information on the Recurring Items page of the MPSE User Manual.
Owner/Authorized Person Name
In the Owner/Authorized Person Name section, the name of the owner or authorized person whose details are currently being viewed is displayed. This field cannot be modified and is for informational purposes only.
Owner/Authorized Person Detail
In the Owner/Authorized Person Detail section, complete the fields to provide details about the owner or authorized person. Required fields are marked by an asterisk (*).
Date of Birth
Enter the owner or authorized person’s birthday in the Date of Birth field in MM/DD/YYYY format.
Social Security Number
Type the owner or authorized person’s Social Security Number (SSN) in the Social Security Number field. Enter the numbers only, MPSE will automatically add the dashes (-).
NPI or UMPI
Type the owner or authorized person’s national provider identifier (NPI) or unique Minnesota provider identifier (UMPI) in the NPI/UMPI field. It is optional to disclose the NPI or UMPI number. If the owner or authorized person does not have an NPI or UMPI number, skip this field.
Current proof of inability to obtain SSN
The Current proof of inability to obtain SSN field shows the documentation that has been uploaded as proof that this owner or authorized person is unable to obtain an SSN. If there is no document uploaded, MPSE will display the words No document exists.
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. This box will not appear if there is no document uploaded in the Current proof of inability to obtain SSN field.
Upload proof of inability to obtain SSN
Use the Upload proof of inability to obtain SSN box to upload documentation that this owner or authorized person is unable to obtain an SSN. You must upload proof of inability to obtain an SSN if you do not enter an SSN and is this option is only allowed if the owner or authorized person’s residential address is located outside of the United States.
Click on the words Upload Supporting Documentation or click on the icon shaped like an eye to open a dialogue box on your computer. This will allow you to select a document to upload. MPSE only allows the following document types to be uploaded: PDF, JPG, and PNG.
Phone Number
Type the owner or authorized person’s 10-digit phone number in the Phone Number field.
Fax Number
Type the owner or authorized person’s 10-digit fax number in the Fax Number field.
Email Address
Type the owner or authorized person’s email address in the Email Address field.
This box is optional. You do not have to give an email address, but if you do, you must provide a valid email address. A valid email follows this format: xxx@yyy.com. For example JohnDoe@organization.com is a valid email address. JohnDoeOrganization.com and JohnDoe@organization are not valid because the first is missing the “@ sign” and the second is missing “.com”.
Does this person have an ownership or control interest in any other Medicaid disclosing entity or any entity that does not participate in Medicaid, but is required to disclose ownership and control interest because of participation in any Title V, XVIII, or XX programs?
Select the Yes option if the owner or authorized person has ownership or control interest in any other Medicaid disclosing entity or any entity that does not participate in Medicaid but is required to disclose ownership and control interest because of participation in any Title V (Maternal and Child Health Services), Title XVIII (Medicare), or Title XX (Social Services) programs. Select the No option if this does not pertain to this owner or authorized person.
If you select Yes, you will be required to disclose that ownership information on the Manage Ownership for Other Medicaid-Disclosing Entities or Non-Medicaid Participants in Title V, XVIII, or XX Programs screen of the MPSE portal.
Has this person ever been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the inception of these programs?
Select the Yes option if the owner or authorized person has ever been convicted of a criminal offence related to that person’s involvement in any program under Medicare, Medicaid, Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the inception of these programs. Select the No option if they have not.
Criminal Exclusion Reason
If you select Yes to the question, “Has this person ever been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid Title XX, or Title XXI in Minnesota or any other state or jurisdiction since the inception of these programs?” you must type an explanation of the reasons this person was convicted of a criminal offense in the Criminal Exclusion Reason box. Your explanation must be 500 characters or less.
Has this person ever had civil money penalties or assessments imposed under section 1128A of the Social Security Act?
Select the Yes option if the owner or authorized person has ever had civil money penalties or assessments imposed under section 1128A of the Social Security Act, or select the No option if they have not.
Civil Exclusion Reason
If you select Yes to the question, “Has this person ever had civil money penalties or assessments imposed under section 1128A of the Social Security Act?” you must type an explanation of the reasons this person had civil money penalties or assessments imposed on them in the Civil Exclusion Reason box. Your explanation must be 500 characters or less.
Has this person ever been excluded from participation in Medicare or any of the State health care programs?
Select Yes if the owner or authorized person has ever been excluded from participation in Medicare or any of the state health care programs, or select the No option if they have not.
Participation Exclusion Reason
If you select Yes to the question, “Has this person ever been excluded from participation in Medicare or any of the State health care programs?” you must type an explanation of the reasons this person was excluded from participation in Medicare or a state health care program in the Participation Exclusion Reason box. Your explanation must be 500 characters or less.
Residential Address
Under Residential Address, provide the owner or authorized person’s home address.
Street Address 1
Type the owner or authorized person’s street address in the Street Address 1 field.
Street Address 2 Type/Data
Select the owner or authorized person’s address type from the Street Address 2 Type drop-down list. Your selectable options are:
Street address type is required if you have typed information into the Street Address 2 Data field. If you have not typed data into the Street Address 2 Data field, then it is optional to select a street address 2 type.
Type your street address data into the Street Address 2 Data field. For example, if you select Apt as your street address 2 type, type your apartment number into the Street Address 2 Data field.
City
Type the city of the owner or authorized person’s residential address in the City field.
State
Select the owner or authorized person’s state of residence from the State drop-down list.
ZIP Code
Type the owner or authorized person’s ZIP code in the ZIP Code field.
County or Tribe
Select the county or tribe of the owner or authorized person’s residential address from the County/Tribe drop-down list if the state of residence is Minnesota.
Relationship Information
You must provide relationship information if the owner or authorized person is related to any other person disclosed as an owner, managing employee or authorized agent of this organization.
Do not add relationship information if the owner or authorized person named on this page is not related to another person disclosed as an owner, managing employee or authorized agent of this organization.
Available Relationship Types
Use the Available Relationship Types to identify the type of relationship the owner or authorized person has with another disclosed owner, managing employee or authorized agent. The available relationship types are:
To identify the type of relationship the owner or authorized person has with another disclosed owner, managing employee or authorized agent, you must move the relationship type from Available Relationship Types to Selected Relationship Types.
To move a relationship type to Selected Relationship Types, click on the relationship type in Available Relationship Types box, which will move it to the Selected Relationship Types box. You may select multiple types if applicable.
Selected Relationship Types
The Selected Relationship Types box displays the relationship types that you have selected from Available Relationship Types.
To remove a relationship type from Selected Relationship Types, click on the relationship type and it will move back to the Available Relationship Types box.
Relationship Information
If a relationship type exists in the Selected Relationship Types, then you are required to type a short description of the relationship that the owner or authorized person has to another person who is disclosed as an owner, managing employee or authorized agent of this organization in the Relationship Information box.
For example, if the owner or authorized person is married to another disclosed person, type married to Jayne Doe.
Continue
Click Continue to save your changes and go to the next page.
Cancel
Click Cancel to go back to the previous page.
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