Hospice Enrollment Criteria and Forms

Revised: June 19, 2020

To enroll as a hospice provider with Minnesota Health Care Programs (MHCP), the hospice must be licensed as a hospice provider by the Minnesota Department of Health (MDH) and certified by Medicare as a provider of hospice services.

Enrollment Criteria

Hospice providers who wish to enroll with MHCP or make enrollment requests can do so in one of the following two ways.

· 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:

· Provider Agreement (DHS-4138) (PDF)

· MHCP fee payment or proof fee was paid to another state or Medicare

or

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

· Individual – Provider Enrollment Application (DHS-4016) (PDF)

· Provider Agreement (DHS-4138) (PDF)

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

· EFT Vendor Number Notification (DHS-3725) (PDF) (optional)

· MHCP fee payment or proof 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 the order they are 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 (RFMI) letter via your MN–ITS mailbox or U.S. mail telling you what we need or 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 Enrollment. Refer to the 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, a new screening fee payment, along with a signed copy of the Provider Entity Sale or Transfer Addendum DHS-5550 (PDF).

Additional Resources

Minnesota Statutes, 256B.0625, subd. 22 (Covered Services - Hospice care)
Minnesota Rules, 9505.0297 (Hospice Care Services – Medical Assistance payments)
Minnesota Rules - 9505.0446 (Hospice Care Payment Rates and Procedures)
Balanced Budget Act of 1997
Code of Federal Regulations, title 42, section 1396a (State plans for medical assistance)