Dental Hygienist Group or Individual Enrollment Criteria and Forms

Revised: July 17, 2024

Dental Hygienist Group

A dental hygienist group is an organization that bills on the behalf of a dental therapist (DT), advanced dental therapist (ADT), or a dental hygienist (DH).

An MHCP-enrolled dental hygienist group may be one of the following:

· Critical access dental provider

· Collaborative practice dental hygienist

· Military and veterans administration hospital, clinic, or care setting

· Oral health educational institution

· Clinic or practice setting, including mobile dental unit, in which at least 50 percent of the total patient base of the DT or ADT:

· Are enrolled as a member with MHCP.

· Have a medical disability or chronic condition that creates a significant barrier to receiving dental care.

· Do not have dental coverage and have a gross family income at or below 200 percent of the federal poverty guidelines (FPG).

How to Enroll – Dental Hygienist Group

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

Use the Minnesota Provider Screening and Enrollment (MPSE) portal:

· Register to access the MPSE portal.

· Create a New Profile Request and complete your enrollment online using the New Organization Provider Enroller instructions.

· Complete the following items and upload them with your request in the MPSE portal:

· Individual Provider Affiliations (DHS-7329) (PDF) form.

· Completed, signed, and initialed Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF).

or

Complete the following documents and fax your materials to 651-431-7462.

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

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF).

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

We process forms in order of date received. Allow 30 days for processing whether enrolling using the MPSE portal or by fax. We will send a request for more information letter to your MN–ITS mailbox or through U.S. Postal Service if we need more information to complete your enrollment.

Dental Hygienist Individual

Individual DT, ADT, or CPDH providers will be enrolled by their employing dental hygienist group and must meet the following requirements:

· Be employed by an MHCP-enrolled group.

· Have entered into a board-approved collaborative agreement or collaborative management agreement (as applicable) with a licensed dentist.

· Have an individual national provider identifier (NPI) number.

· DTs and CPDHs must be licensed by the Board of Dentistry in the state in which they practice.

· ADTs must be certified by the Minnesota Board of Dentistry.

How to Enroll – Dental Hygienist Individual

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

Use the Minnesota Provider Screening and Enrollment (MPSE) portal:

· Complete an Organization to Individual Affiliations request.

· When selecting the enrollment record type, use Allied Dental Professional.

· Complete the following items and upload them with your request in the MPSE portal:

· Collaborative agreement with a licensed dentist.

· Current dental hygienist license from the Minnesota Board of Dentistry (DH only)

· Current dental therapist license from the Minnesota Board of Dentistry (DT only).

· Current ADT certification from the Minnesota Board of Dentistry (ADT only).

· Completed, signed, and initialed Collaborative Practice Dental Hygienist Assurance Statement (DHS-6025) (PDF) (CPDH only).

· Completed, signed, and initialed Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF).

or

Complete the following documents and fax your materials to 651-431-7462.

· Individual Provider Enrollment Application (DHS-4016) (PDF) (select provider type Allied Dental Professional 31)

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or MCO In-Network Provider Agreement (DHS-8355) (PDF).

· Collaborative Practice Dental Hygienist Assurance Statement (DHS-6025) (PDF) – for DH only

· Copy of current license and certification from the Board of Dentistry (if applicable)

· Copy of current ADT certificate from Board of Dentistry (ADT only)

· Copy of current DT certificate from the Board of Dentistry

If you are dually licensed as an advanced dental therapist or dental therapist and a dental hygienist, this information must be included on your enrollment application. Copies of both license types must be submitted with your enrollment application.

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

We process forms in order of date received. Allow 30 days for processing whether enrolling using the MPSE portal or by fax. We will send a request for more information letter to your MN–ITS mailbox or through U.S. Postal Services if we need more information to complete your enrollment.

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services (CMS) final federal provider screening regulations.

MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all required forms and documents to DHS.

Refer to Revalidation in the Provider Screening Requirements section under Provider Basics in the MHCP Provider Manual for important information, including timelines, about the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.

Reporting Changes

Report any changes made on a record to MHCP. Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual for details.

Legal References

Minnesota Statutes, 150A.105 (Dental Therapist)
Minnesota Statutes, 150.106 (Advanced Dental Therapist)
Minnesota Statutes, 150A.10 (Allied Dental Personnel)
Minnesota Statutes, 150A.10, subdivision 1a (Collaborative practice authorization for dental hygienists in community settings)
Code of Federal Regulations, title 42, section 440.100 (Dental services)