Moving Home Minnesota (MHM) Enrollment Criteria and Forms

Revised: June 17, 2021

How to Enroll

Providers can enroll with MHCP or make enrollment requests for HCBS service(s) 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.

· You will also need to upload the following:

· A copy of the contract from the lead agency (for contracted case management services only)

· Copies of licenses, certification and registrations, if indicated in MPSE.

· Assurance statement(s), if indicated in MPSE.

· Provider Agreement (DHS-4138) (PDF)

· Request for Licensing Agency ID Number (DHS-3891) (PDF), if applicable. See Background Study

· Proof of completion of the HCBS Waiver and AC Provider Training 101 competency test. See HCBS Waiver and AC Provider Training 101 Proof of Completion for a list of acceptable forms of proof. A copy of your general liability insurance certificate, if indicated in MPSE

or

· Complete the following documents for each location providing services and fax your materials to MHCP Provider Eligibility and Compliance at 651-431-7493.

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

· MHCP Provider Agreement (DHS 4138) (PDF)

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

· HCBS Programs Service Request Form (DHS 6638) (PDF)

· Establish your Direct Deposit/Electronic Funds Transfer (EFT) (DHS 3725) (PDF)

· Proof showing you are qualified to provide the services including but not limited to:

· A copy of the contract from the lead agency

· Copies of licenses, certifications and registrations when appropriate

· The Home and Community Based Services (HCBS) Programs Lead Agency Provider Enrollment Request Form (DHS 6383) (PDF) when appropriate

· Assurant statements as appropriate (see the HCBS Programs Service Request Form (DHS 6638) (PDF) to determine which services require an assurance statements and a link to the appropriate assurance statement for that service)

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.

Adding Services to Current Enrollment Record

To add additional MHM services to your current enrollment record:

1. Use the HCBS Programs Service Request Form (DHS 6638) (PDF) to list the service(s) you want to provide and report your qualifications to provide the service(s)

2. Communicate with the lead agency to ensure your contracts include the new service as appropriate

3. Complete and submit the following via the MPSE portal or fax to MHCP Provider Eligibility and Compliance at 651-431-7493:

· Request for MHCP to add the service(s) to your file

· Proof showing you are qualified to provide the services

· Assurance statements, as appropriate (see the HCBS Programs Service Request Form [DHS 6638] [PDF] to determine which services require an assurance statements and a link to the appropriate assurance statement for that service.)

· Moving Home Minnesota – Transition Planning, Transition Coordination and Demonstration Case Management Providers – Applicant Assurance Statement (DHS 3879) (PDF) to enroll to provide Transition Planning and Coordination

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 notify MHCP any time a change occurs. Report any changes by submitting a request using the MPSE portal or by faxing the following forms to MHCP Provider Eligibility and Compliance at 651-431-7493.

· Organization Profile Change Form (DHS 3535A) (PDF) to report change in affiliated providers, address, etc.

· Disclosure of Ownership and Control Interest (DHS 5259) (PDF) to report changes in ownership or managing employees with controlling interest (ownership changes must be reported at least 30 days before the change occurs)

· Electronic Remittance Advice (RA) Request Form (DHS 4718) (PDF) to add or remove electronic RA to or from a provider or billing organization

· EFT bank change form to report changes to your direct deposit information

MHCP will process the change information and notify the agency if any further documentation is necessary to continue or maintain enrollment with MHCP in relation to the changes.