Targeted Case Management (TCM) Enrollment Criteria and Forms

Revised: June 2, 2023

The local county or tribal agency approves targeted case managers (individuals or agencies), but counties and tribes cannot activate a case manager’s Minnesota Health Care Programs (MHCP) enrollment. Only MHCP can change an approved county case manager’s status to active. MHCP enrolls the following types of targeted case managers:

· Adult mental health

· Children’s mental health

· Child welfare

· Relocation Services Coordination (RSC)

Enrollment Criteria

Providers who want to enroll with MHCP or make enrollment requests may do so in one the following two ways:

· Register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal through MN–ITS

or

· Complete the following documents and fax to MHCP Provider Eligibility and Compliance at 651-431-7462:

· Organization – Provider Enrollment Application (DHS-4016A) (PDF) (for agencies and groups)

· Home and Community Based Services (HCBS) - Provider Enrollment Application (DHS-4015) (PDF) (for RSC only)

· Provider Agreement (DHS-4138) (PDF)

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

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

· MHCP provider screening fee payment confirmation or proof the fee was paid to another state or Medicare.

· Refer to the MHCP Provider Screening Requirements for information on application fees. You can pay the application fee using the MHCP Provider Screening Fee Collections System.

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

MHCP Provider Eligibility and Compliance processes forms in date order received. Allow 30 days for processing. If more information is needed to complete your enrollment, you will receive a notice or letter telling you what is missing or what you need to do to complete your enrollment.

Interactive Video

The following MHCP-enrolled TCM providers may deliver TCM through interactive video:

· Child Welfare Targeted Case Management

· Children’s Mental Health Targeted Case Management

· Adult Mental Health Targeted Case Management

· Vulnerable Adult/Developmental Disability Targeted Case Management

Organizational providers who want to deliver and bill for TCM services using interactive video must assure they meet the requirements of the interactive video policy and attest to the safety and effectiveness of interactive video for the person served, according to Minnesota Statutes 256B.0625, subdivision 20b. Complete and submit the Targeted Case Management Provider Interactive Video Assurance Statement (DHS-8398) (PDF) to DHS through the MPSE portal or by fax to add interactive video services to your current enrollment record.

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 the Change of Enrollment Information in the Provider Requirements section of the MHCP Provider Manual for details.

Additional Resources

Minnesota Statutes 256B.0621 Covered Services: Targeted case management
Minnesota Statutes 245.462 Definitions; Case management service provider
Minnesota Statutes 245.4711 Case Management Services
Minnesota Statutes 256B.0625, subdivision 20b, Targeted case management through interactive video