Provider Participation Requirements – Rule 101

Revised: March 17, 2023

Rule 101 requires providers who want to be paid for other state-sponsored health care programs to participate in Minnesota Health Care Programs (MHCP) and accept new patients (per current procedural terminology [CPT] definition) who are MHCP members on a continuous basis. Other state-sponsored health care programs include:

· State employees' health insurance plans

· Workers' compensation insurance

· Public employees' insurance program

· Health insurance plans offered to local statutory or home rule charter city, county, and school district employees

MHCP Caseload Limits

Non-dental providers may limit acceptance of new patients who are MHCP members if at least 20 percent of the provider’s active caseload are MHCP members, based on the following calculations:

1. Determine annual active patient caseload by calculating the total number of patient encounters that result in a claim during the provider's most recent fiscal year. Or, if enrolled as a provider for less than a year, the total number of patient encounters that result in a claim during the period between enrollment and the end of the provider’s fiscal year.

2. Determine patient encounters from all service sites enrolled under the provider's NPI or UMPI but count only one patient encounter per patient per day regardless of the number of services sites involved in the patient’s health care. A provider may count recipients receiving health services on a fee-for-service basis and under a prepaid contract.

Dental providers may limit acceptance of new MHCP members at their practice locations within the seven-county metro area (Anoka, Carver, Dakota, Hennepin, Ramsey, Washington and Scott) if they meet one of these conditions:

· MHCP members make up at least 10 percent of their annual active caseload

· The provider accepts new MHCP members who are children with special health care needs

Dental practices located outside of the seven-county metro area who want to be paid for other state-sponsored health care programs are not subject to the required 10 percent annual active case load.

For purposes of this seven-county metro provision, children with special health care needs are children up to 18 years of age who meet the following criteria:

· Require health and related services beyond that required by children generally

· Have or are at risk for a chronic physical, developmental, behavioral, or emotional condition, including:

· Autism

· Bleeding and coagulation disorders

· Cancer

· Developmental disabilities

· Down syndrome and other genetic disorders

· Epilepsy, cerebral palsy, and other neurological diseases

· Endocrinopathy

· Fetal alcohol syndrome

· Immunodeficiency disorders

· Visual impairment or deafness

· Other conditions as designated by the commissioner after consultation with representatives of pediatric dental providers and consumers

The previous listed requirements apply only to dental practices located within the seven-county metro area.

All providers must notify MHCP in writing before limiting acceptance of MHCP new members, and include active patient caseload data used to calculate the percentage of patients who are members. This form can be uploaded through the Minnesota Provider Screening and Enrollment (MPSE) Portal or faxed to 651-431-7054. Keep a signed copy for your records.

· Non-dental providers, use Limiting MHCP Caseload Assurance Statement (DHS-5078A) (PDF)

· Dental providers, use Limiting MHCP Caseload Assurance Statement (Dental) (DHS-5078) (PDF)

If MHCP accepts the notice, the acceptance will be effective 10 days after MHCP notifies the provider in writing, and will remain in effect for the remainder of the year. Providers who wish to continue limiting MHCP caseload must file a new notice each year. A provider who has a contract with an MHCP-contracted MCO must notify each plan of its intention to limit acceptance of new MHCP patients.

MHCP shares lists of providers who comply with participation requirements quarterly with the state Departments of Commerce, Management and Budget, and Labor and Industry. A provider who fails to comply with the requirements of Rule 101 will be excluded from state-sponsored health care programs. MHCP will notify a provider if we have reason to believe they are not complying with these participation requirements. The provider will have 30 days to provide MHCP with evidence of participation compliance. After the response period expires, those who have not submitted evidence of compliance will be excluded from participation in the other state health care programs.

Legal References

Minnesota Statutes, 62D.04, subdivision 5 (Issuance of Certificate Authority, Participation; government programs)
Minnesota Statutes, 256B.0644 (Reimbursement under Other State Health Care Programs) Minnesota Rules, 9505.5200-9505.5220 and 9505.5240 (Department Health Care Program Participation Requirements for Vendors and Health Maintenance Organizations)