Substance Use Disorder (SUD) Services Enrollment Criteria and Forms

Revised: November 5, 2025

Review the following for information about enrolling as an organization or an individual.

· SUD Services Organization Enrollment

· Licensed Professional in Private Practice

· Counties and Tribes

Refer to the Recovery Community Organization (RCOs) Enrollment Criteria and Forms section of the MHCP Provider Manual to enroll as an RCO.

To enroll as an SUD services provider with Minnesota Health Care Programs (MHCP), a provider must:

· Be an eligible vendor of SUD services according to Minnesota Statutes, 254B.05, subdivision 1. Exceptions include out-of-state providers who must be licensed in the state in which they provide services and approved by the Behavioral Health Administration (BHA); and free-standing room and board providers who must also be approved by the BHA before MHCP enrollment. Email bhd.enhancements.dhs@state.mn.us if you have questions or want information about becoming an approved SUD out-of-state provider. Visit the Free Standing Room and Board Programs webpage for more information about free standing room and board programs.

· Certify ASAM Levels of Care you will provide. Visit the ASAM resources for Minnesota SUD treatment providers for instructions on ASAM certification.

· You must also enroll and participate in the Drug and Alcohol Abuse Normative Evaluations System (DAANES) after enrolling as an MHCP SUD provider. Contact the DAANES coordinator by dhs.daanes@state.mn.us for DAANES training and documentation requirements. This does not apply to agencies who are solely free-standing room and board providers.

How to Enroll

SUD services providers who wish to enroll with MHCP or make enrollment requests can do so in one of the following 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. You will be required to upload copies of the agreements, assurance statements, licenses and proofs of insurance required for your provider type, which are specified in the following sections.

or

Submit Forms via Fax

Complete the required documents listed in the following sections to enroll for your specific provider type. Fax all forms to MHCP Provider Eligibility and Compliance at 651-431-7462. 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 your MN–ITS mailbox, if you have an account) telling you what you need to do to complete your enrollment.

Licensed SUD Programs or Organizations Enrollment Requirements

The following enrollment forms are required if submitting your enrollment request by fax or through the MPSE Portal, except when otherwise indicated:

· Organization – Provider Enrollment Application (DHS-4016A) (PDF) (Not required if enrolling through the MPSE Portal)

· 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 Managed Care Organization In-network Provider Agreement (DHS-8355) (PDF)

· Disclosure of Ownership and Control Interest (DHS-5259) (PDF) (Not required if enrolling through the MPSE Portal)

· Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491) (PDF)

· Substance Use Disorder (SUD) Services and Level of Care Assurance Statement (DHS-6381) (PDF), if applicable, for each location according to the services provided

· EFT Supplier ID Notification (DHS-3725) (PDF) (Optional, not required if enrolling through the MPSE Portal)

· Proof of general liability insurance in the amount of $2 million for each occurrence according to Minnesota Statutes, 254B.05 (The certificate holder must be listed as: Minnesota Department of Human Services (DHS) Provider Eligibility and Compliance, P.O. Box 64987, St. Paul, MN 55164)

· Proof of employee dishonesty bond in the amount of $10,000 if the provider has custody or control of money or property belonging to a client

· Proof that a fee was paid to Minnesota Department of Human Services (DHS), another state Medicaid agency or Medicare

· Proof of state or Tribal license, such as:

· 245G Substance Use Disorder treatment provider license

· 245F Withdrawal Management Program license

· Children’s residential facility with SUD certification

· Appropriate Tribal license

· Free-standing-room-and-board approval letter provided by BHA

· Appropriate SUD treatment license for out-of-state-providers for their state and approval letter provided by Behavioral Health Division

Credentials to enroll as an Agency
Several types of licenses are acceptable for reimbursement including:

· Minnesota Statutes, 245G Substance Use Disorder treatment provider license

· Minnesota Statutes, 245F Withdrawal Management Programs

· Children’s Residential Facility with chemical dependency certification

· Appropriate Tribal license

· Free-standing room and board approval letter from Behavioral Health Division

· Appropriate SUD treatment license for out-of-state providers for their state, with approval from Behavioral Health Division

You must enroll each service delivery location if you have more than one service delivery location.

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

Certifying an ASAM Level of Care

Providers must submit an ASAM Certification Checklist (DHS-7325) (PDF) and accompanying documents listed under the ASAM Certification heading on the ASAM resources for Minnesota SUD treatment providers webpage to certify an ASAM level of care. Providers must meet the requirements listed on these forms and submit the forms to the DHS to be eligible to provide, bill and be paid by MHCP for SUD services.

Existing MHCP organizations adding SUD services
Hospitals, federally qualified health clinics, and rural health clinics can add SUD services to their existing MHCP records when they become a licensed SUD provider. If adding a new ASAM level of care, providers must also submit an attestation or certification that they meet the ASAM criteria standards for that level of care. Submit the following documentation, either through the MPSE Portal by following the New Enrollment Record guide, or by fax:

· Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491) (PDF)

· Substance Use Disorder (SUD) Services and Level of Care Assurance Statement (DHS-6381) (PDF) if applicable, for each location according to the services provided

· Proof of general liability insurance in the amount of $2 million for each occurrence according to Minnesota Statutes, 254B.05 (The certificate holder must be listed as: Minnesota DHS Provider Eligibility and Compliance, P.O. Box 64987, St. Paul, MN 55164)

· Proof of employee dishonesty bond in the amount of $10,000 if the provider has custody or control of money or property belonging to a client

· Proof that a fee was paid to Minnesota DHS, another state Medicaid agency or Medicare.

· Proof of state or Tribal license, such as:

· 245G Substance Use Disorder treatment provider license

· 245F Withdrawal Management Program license

· Children’s residential facility with SUD certification

· Appropriate Tribal license

· For out-of-state-providers, an appropriate SUD treatment license for their state

Service Rate Enhancements

Service rate enhancements are available for eligible vendors when the provider meets the standards for each rate enhancement as defined in Minnesota Statutes, 254B.05, subdivision 5 (c).

Service rate enhancements are available for:

· Programs that serve parents with the children

· Culturally specific or culturally responsive programs as defined in Minnesota Statutes, 254B.01, subdivision 4a.

· Disability responsive programs as defined in Minnesota Statutes, 245B.01, subdivision 4b.

· Programs that offer medical services

· Programs that offer services to an individual with co-occurring mental health and substance use disorder problems.

Culturally specific or responsive and disability responsive enhancements are approved through the Behavioral Health Administration (BHA). Additional information in the following attestation forms is necessary to request these enhancements. Complete the following form or forms that apply to the enhancement or enhancements you’re requesting:

· Culturally Specific or Culturally Responsive Program Rate Enhancement Attestation for Licensed Substance Use Disorder Programs

· Disability Responsive Programs Rate Enhancement Attestation for Licensed Substance Use Disorder Programs.

Email the completed form or forms to bhd.enhancements.dhs@state.mn.us to obtain approval.

Service rate enhancements for programs that serve parents with children, medical services, or services to individuals with co-occurring mental health and substance use disorder are approved through the Licensing Division. Contact DHS Licensing for more information on approval for these service enhancements.

How to enroll as a Licensed Professional in Private Practice to provide SUD services

The following only applies to individuals who are in their own private practice. If you are an individual that’s already employed by an organization, this does not apply to you.

A licensed professional in private practice must be someone who is licensed under Minnesota Statutes, 148F, or is exempt from licensure under that chapter, but is otherwise licensed to provide alcohol and drug counseling services; practices solely within the permissible scope of the individual's license as defined in the law authorizing licensure; and does not affiliate with other licensed or unlicensed professionals to provide alcohol and drug counseling services.

Affiliation includes but is not limited to:

· using the same electronic record system as another professional, except when the system prohibits each professional from accessing the records of another professional;

· advertising the services of more than one professional together;

· accepting client referrals made to a group of professionals;

· providing services to another professional's clients when that professional is absent; or

· appearing in any way to be a group practice or program.

Affiliation does not include:

· conferring with another professional;

· making a client referral to another professional;

· contracting with the same agency as another professional for billing services;

· using the same waiting area for clients in an office as another professional; or

· using the same receptionist as another professional if the receptionist supports each professional independently.

To enroll with MHCP as a licensed professional in private practice, the professional must:

· Be at least 18 years of age

· Have three or more years of experience providing individual and group counseling to individuals with substance use disorders

· Have knowledge of and know the implications of Minnesota Statutes 245G, 245A.65, 626.557, and 260E

Licensed professionals in private practice can provide comprehensive assessments, individual and group counseling, and treatment coordination services. They may not provide peer recovery support services. Treatment services, plans, and discharge must be documented according to Minnesota Statutes 245G.06 and 245G.07.

The credentials eligible to enroll to provide substance use disorder services are:

· Licensed Alcohol and Drug Counselor (LADC); or

· Upper Midwest Indian Counsel on Addictive Disorders (UMICAD) Level III certification (Submit certification. Individuals enrolling with MHCP with the UMICAD Counselor Level III credential may only provide services to individuals identifying as Native American.); or

· One of the following (submit license):

· Licensed independent clinical social worker

· Marriage and family therapist

· Physician

· Occupational therapist

· Psychologist

· Licensed professional clinic counselor

· Nurse practitioner

· Clinical nurse specialist

· Physician assistant

Individuals enrolling with a license other than a LADC must also submit documentation indicating you meet one of the following:

· Completion of at least a baccalaureate degree with a major or concentration in social work, nursing, sociology, human services, or psychology, or licensure as a registered nurse; successful completion of a minimum of 120 hours of classroom instruction in which each of the core functions listed in Minnesota Statutes, 148F is covered; and successful completion of 440 hours of supervised experience as an alcohol and drug counselor, either as a student or a staff member

· Completion of at least 270 hours of drug counselor training in which each of the core functions listed in Minnesota Statutes, 148F is covered, and successful completion of 880 hours of supervised experience as an alcohol and drug counselor, either as a student or staff member

· Current certification as an alcohol and drug counselor or alcohol and drug counselor reciprocal, through the evaluation process established by the International Certification and Reciprocity Consortium Alcohol and Other Drug Abuse, Inc.

· Completion of a bachelor’s degree including 480 hours of alcohol and drug counseling education from an accredited school or educational program and 880 hours of alcohol and drug counseling practicum

· Employment in a program formerly licensed under Minnesota Rules, parts 9530.5000 to 9530.6400, and successful completion of 6,000 hours of supervised work experience in a licensed program as an alcohol and drug counselor before Jan. 1, 2005

New providers
A National Provider Identifier (NPI) number is required before enrollment (review the National Plan & Provider Enumeration System’s Main Page to learn how to apply for an NPI).

Licensed Professionals in Private Practice who wish to enroll with MHCP or make enrollment requests can do so in one of the following 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. You will be required to upload copies of the agreements, assurance statements, licenses and proofs of insurance required for your provider type, which are specified in the following sections.

or

Submit Forms via Fax

Complete the required documents listed in the following sections to enroll for your specific provider type and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7462.

Required documents:

· MHCP Individual Practitioner Provider Enrollment Application (DHS-4016) (PDF) (Not required if enrolling through the MPSE Portal)

· 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 Managed Care Organization In-network Provider Agreement (DHS-8355) (PDF)

· Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491) (PDF)

· Substance Use Disorder (SUD) Provider Assurance Statement Professionals (DHS-7754) (PDF)

· Proof of general liability insurance in the amount of $2 million for each occurrence according to Minnesota Statutes, 254B.05 (The certificate holder must be listed as: Minnesota DHS Provider Eligibility and Compliance, P.O. Box 64987, St. Paul, MN 55164)

· Proof of employee dishonesty bond in the amount of $10,000 if the provider has custody or control of money or property belonging to a client

· Fee not required

Providers who are already enrolled with MHCP as something other than an LADC
Individual providers previously enrolled with MHCP can add SUD services to their existing MHCP records. Add SUD services to existing MHCP records by submitting the following documentation, either through the MPSE portal by following the New Enrollment Record guide, or by fax:

· Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491) (PDF)

· Substance Use Disorder (SUD) Provider Assurance Statement - Professionals (DHS-7754) (PDF)

· Proof of general liability insurance in the amount of $2 million for each occurrence according to Minnesota Statutes, 254B.05 (The certificate holder must be listed as: Minnesota DHS Provider Eligibility and Compliance, P.O. Box 64987, St. Paul, MN 55164)

· Proof of employee dishonesty bond in the amount of $10,000 if the provider has custody or control of money or property belonging to a client

· Fee not required

Counties and Tribes

Counties and Tribes are eligible to enroll with MHCP to provide treatment coordination, comprehensive assessments, and peer recovery support services. County or tribal employees who want to provide comprehensive assessments must have staff who meet the criteria of an alcohol and drug counselor (Minnesota Statutes, 245G.11, subdivision 5). The comprehensive assessments must be done according to the requirements listed in Minnesota Statutes, 254A.19, subdivision3 (or requirements determined by the Tribe).

County or Tribal employees may also provide treatment coordination and peer recovery support services.

Those who would like to provide treatment coordination must be qualified according to Minnesota Statutes, 245G.11, subdivision 7. Treatment coordinators:

· are skilled in the process of identifying and assessing a wide range of client needs,

· are knowledgeable about local community resources and how to use those resources for the benefit of the client,

· have successfully completed 30 hours of classroom instruction on treatment coordination for an individual with substance use disorder,

· have either a bachelor’s degree in one of the behavioral sciences or related fields or current certification as an alcohol and drug counselor, level I, by the Upper Midwest Indian Council on Addictive Disorders,

· have at least 2,000 hours of supervised experience working with individuals with substance use disorder.

Alcohol and drug counselors (Minnesota Statutes, 245G.11, subdivision 5) can also provide treatment coordination. If the treatment coordinator is not an alcohol and drug counselor, they must receive at least one hour of supervision regarding individual service delivery from an alcohol and drug counselor, or a mental health professional who has substance use treatment and assessments within the scope of their practice, on a monthly basis. Treatment coordination services are described in Minnesota Statutes, 245G.07, subdivision 1 (5) and provided one to one. Treatment coordination services include:

· assistance in coordination with significant others to help in the treatment planning process whenever possible;

· assistance in coordination with and follow up for medical services as identified in the treatment plan;

· facilitation of referrals to substance use disorder services as indicated by a client's medical provider, comprehensive assessment or treatment plan;

· facilitation of referrals to mental health services as identified by a client's comprehensive assessment or treatment plan;

· assistance with referrals to economic assistance, social services, housing resources, and prenatal care according to the client’s needs;

· life skills advocacy and support accessing treatment follow-up, disease management and education services, including referral and linkages to long-term services and supports as needed; and

· documentation of the provision of treatment coordination services in the client’s file.

Counties and Tribes that would like to provide peer recovery services must have individuals qualified according to Minnesota Statues, 245G.11, subdivision 8. Recovery peers must:

· have a minimum of one year in recovery from substance use disorder;

· hold a current credential from the Minnesota Certification Board, the Upper Midwest Indian Council on Addictive Disorders, or the National Association for Alcoholism and Drug Abuse Counselors that demonstrates skills and training in the domains of ethics and boundaries, advocacy, mentoring and education, and recovery and wellness support. Individuals who receive a credential from a Tribal nation when providing peer recovery support services in a Tribally licensed program must also meet this requirement;

· not be classified or treated as an independent contractor when hired on or after July 1, 2024. Beginning Jan. 1, 2025, a recovery peer must not be classified or treated as an independent contractor.

Recovery peers must work under the supervision of a licensed alcohol and drug counselor or mental health professional who meets qualifications under Minnesota Statutes, 245I.04, subdivision 2, and must:

· provide individualized peer support and individualized recovery planning to each client;

· promote a client's recovery goals, self-sufficiency, self-advocacy, and development of natural supports; and

· support a client's maintenance of skills that the client has learned from other services.

Supervision of recovery peers must consist of:

· meeting with the recovery peer face-to-face, either remotely or in person, at least once per month;

· reviewing individual recovery plans, as defined in section 254B.01, subdivision 4e;

· reviewing documentation of the peer recovery support services provided for clients;

· client updates, discussion of ethical considerations, and addressing any other questions or issues relevant to peer recovery support services may also be included as part of recovery peer supervision.

Additional requirements for peer recovery support services can be found in 254B.052 (as of Jan. 1, 2025).

You must complete and submit the following forms to enroll as a county or Tribe to provide comprehensive assessments, peer recovery support services or treatment coordination:

· Substance Use Disorder (SUD) Provider Assurance Statement - Counties and Tribes (DHS-7820) (PDF)

· Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491) (PDF)

· Proof of general liability insurance in the amount of $1.5 million for each occurrence according to Minnesota Statutes, 254B.05 (The certificate holder must be listed as: Minnesota DHS Provider Eligibility and Compliance, P.O. Box 64987, St. Paul, MN 55164)

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 Enrollment with MHCP section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes, 254B (Substance Use Disorder Treatment)
Minnesota Statutes, 245G (Substance Use Disorder Licensed Treatment Facilities)
Minnesota Statutes, 245F (Withdrawal Management)
Code of Federal Regulations, title 42, section 440.130 (Diagnostic, screening preventive and rehabilitative services)