PCA Provider Agency Enrollment

Revised: March 3, 2021

· How to Enroll

· Revalidation

· Reporting Changes

How to Enroll

Your initial personal care provider organization (PCPO) or personal care assistance (PCA) Choice application to enroll with Minnesota Health Care Programs (MHCP) must include all items listed in this section.

Owners, managing employees and qualified professionals are required to attend PCA agency training before completing the enrollment process. Any additional business sites or locations must also submit a complete application.

PCPO and PCA Choice providers must follow these steps:

1. Attend the training PCA Steps for Success.

2. Pay the application fee

3. Either register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal,

or

Complete the following and fax to Provider Eligibility and Compliance at 651-431-7465 along with any required documents.

· PCPO or PCA Choice Provider Enrollment Application (DHS-4022) (PDF)

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

· Qualified Professional (QP) Acknowledgement (DHS-4022C) (PDF)

· Direct Deposit Authorization for Electronic Funds Transfer (EFT)

· MHCP Provider Agreement (DHS-4138) (PDF) and one or both of the following:

· Provider Agreement Addendum – PCPO (DHS-4022A) (PDF)

· Provider Agreement Addendum – PCA Choice Provider (DHS-4022B) (PDF)

· Copy of certificate of registration with the Office of the Secretary of State of Minnesota

· Copy of PCA Steps for Success certificate for owners, managing employees, and qualified professionals

· PCA Agency Assurance Statement (DHS-6005) (PDF)

· Designation of PCA Billing Person (DHS-6000) (PDF)

· Copy of certificate of liability insurance. Copy of your general liability insurance certificate naming “DHS PE” as a certificate holder on the document, with the following address listed: PO Box 64987, St. Paul, MN. 55164-0987.

· Copy of Workers’ Compensation insurance (not required for Medicare-certified or Class A licensed agencies)

· Copy of fidelity bond in the amount of $20,000

· Copy of PCA Agency Surety Bond (DHS-6033) (PDF). The Surety bond must be in the amount of $50,000 for first time enrolling providers

**Medicare-certified home health agencies may submit the Organization – Provider Enrollment Application (DHS-4016A) (PDF) if also doing services other than PCA. If providing PCA services through the enrolled home health agency they must also follow steps 2-3 of the enrollment process above.

4. 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 request for more information letter via U.S. mail (or in your MN–ITS mailbox, if you have an account) telling you 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

You must report any changes made on a provider record to MHCP Provider Eligibility and Compliance. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Ongoing Reporting Requirements

When a change occurs in one of the following:		Fax the appropriate form or information from this column (below) to MHCP Provider Enrollment:
Name of business:		Group, Facility or Billing Entity MHCP Provider Information Change Form (DHS-3535A) (PDF)
Address, phone number or fax number:
Ownership (must be reported 30 days before the change occurs)	(sale of business, add or remove owners, directors, managers, board members, other entities with control interest in the business, etc.)	Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF)
Management
Qualified Supervising Professional		Qualified Professional (QP) Acknowledgement (DHS-4022C) (PDF)
Direct deposit or bank information		EFT Bank Change Request (PDF)
Billing person		Designation of PCA Billing Person (DHS-6000) (PDF)
Bonds and insurances		Copy of new, changed or renewed bonds or insurances. Submit at the time of the change.

You must also meet ongoing requirements of other state agencies for Minnesota businesses.