Medical Supplier Enrollment Criteria and Forms

Revised: April 7, 2022

To enroll as medical supplier with Minnesota Health Care Programs (MHCP), the supplier must be enrolled with Medicare, with one exception, when the supplier only provides services to pediatric patients.

Enrollment Criteria

Medical suppliers 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 Provider Agreement (DHS-4138) (PDF) and a completed copy of DMEPOS Surety Bond (DHS-3869) (PDF).

or

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

· Organization Enrollment Application (DHS-4016A) (PDF)

· MHCP Provider Agreement (DHS-4138) (PDF)

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

· DMEPOS Surety Bond (DHS-3869) (PDF)

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

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 notice or letter 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.

Additional Resources

Minnesota Statutes 148.171, subdivision 16 (Prescribing)
Minnesota Statutes, 256B.0625, subdivision 31 (Medical supplies and equipment)
Minnesota Rules, 9505.0310; 9549.0020 (Medical Supplies and Equipment; Definitions)
Minnesota Rules, 9505.0365; 9505.0445 (Prosthetic and Orthotic Devices; Payment Rates)