Home Health Agency Enrollment Criteria and Forms

Revised: June 20, 2025

· How to Enroll

· Home Health Agency (HHA)

· HHAs Providing Personal Care Assistance (PCA)

· HHAs Providing Community First Services and Supports (CFSS)

· Enrollment Processing Timeline

· Revalidation

· Reporting Changes

· Legal References

How to Enroll

Home Health Agency (HHA)
Home health agencies (HHAs) must be Medicare-certified through the Centers for Medicare & Medicaid Services (CMS) before applying and enrolling with Minnesota Health Care Programs (MHCP).

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

· Register to access the Minnesota Provider Screening and Enrollment (MPSE) portal and complete your enrollment online using the MPSE portal. Upload the following documents in MPSE:

· A completed and signed copy of the Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF). Upload to the Agreements/Addendums screen in MPSE.

· 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.

· Copy of comprehensive home care license

· Copy of CMS Medicare approval notice

or

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

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

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

· A completed and signed copy of the Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (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.

· Copy of comprehensive home care license

· Copy of CMS Medicare approval notice

· Include the EFT Supplier ID Notification (DHS-3725) (PDF) if the HHA group is a pay-to provider.

HHAs Providing Personal Care Assistance (PCA)

DHS will begin to slowly phase out the PCA program beginning October 1, 2024, to transition to Community First Services and Supports (CFSS).

HHAs must be enrolled with MHCP before providing PCA services. Enrolled HHAs who want to provide PCA services must also submit the following forms either using MPSE or by fax:

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

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

· PCA Agency Surety Bond (DHS-6033) (PDF)

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

· Copy of your general liability insurance certificate naming “Provider Eligibility and Compliance” as a certificate holder on the document, with the following address listed: P.O. Box 64987, St. Paul, MN, 55164

· To add personal care provider organization (PCPO) - PCPO Provider Agreement Addendum (DHS-4022A) (PDF)

· To add PCA Choice - PCA Choice Provider Agreement (DHS-4022B) (PDF)

· To add both PCPO and PCA Choice, complete both the PCPO Provider Agreement Addendum (DHS-4022A) and the PCA Choice Provider Agreement (DHS-4022B)

To add PCA services, follow the Steps to Add a New Service in MPSE or fax the previously listed forms and documents.

HHA must enroll and affiliate their individual PCA workers to provide PCA services.

HHAs Providing Community First Services and Supports

With the transition of PCA to CFSS on October 1, 2024, homecare service providers will now be required to complete the training requirements of a CFSS agency. The following agency staff are required to submit CFSS training certificates:

· All managing employees (directly or indirectly involved in the day-to-day operations of the business)

· All owners with a 5% or more controlling interest who are directly involved with day-to-day operations of the business

Home health agencies who enrolled prior to October 1, 2024, and have been providing PCA services must submit a CFSS transition training certificate for the staff previously listed. Refer to the PCA/CFSS provider agency training requirements (state.mn.us) for more information on the training.

Home health agencies who enroll after October 1, 2024, must have their managing employees and direct owners (previously listed) attend the three-day CFSS Steps for Success workshop, and provide the training certificate as a part of their CFSS enrollment.

To enroll after Oct. 1, 2024, to provide CFSS services, home health agencies must submit the following documents using MPSE or by fax:

· CFSS Agency Agreement Addendum (DHS-8160A) (PDF)

· CFSS Agency Assurance Statement (DHS-8560) (PDF)

· Copy of CFSS Steps for Success training certificate for owners and managing employees

· 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 fidelity bond in the amount of 20,000

· Copy of the Community First Services and Supports (CFSS) Agency Surety Bond (DHS-8558) (PDF). The surety bond must be in the amount of $50,000 for first time enrolling providers.

All enrolling providers must review and keep a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF).

Enrollment Processing Timeline

We process applications and requests 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 through your MN–ITS mailbox or U.S. Postal Service if we need more information to complete your enrollment.

Revalidation

MHCP is required to follow the 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 listed under How to Enroll to Provider Eligibility and Compliance at 651-431-7462.

We recommend using the MPSE portal and following the instructions in the Revalidation section of the MPSE user manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original Welcome Letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome Letter.

Refer to Revalidation in the Provider Screening Requirements section of 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. It is recommended to use the MPSE portal to process your revalidation.

Reporting Changes

Report any changes made on a provider record to DHS. Using the MPSE portal is the most effective way to update provider records. Refer to the MPSE Requests section of the MPSE User Manual for step-by-step instructions to complete a request in the MPSE portal.

Refer to Changes to Enrollment in the Enroll with MHCP section of the MHCP Provider Manual to request changes to your provider records using the fax option.

Changes that occur before notifying MHCP or missing or incorrect information may result in billing suspension. See Minnesota Statutes, 256B.04, subdivision 21(d).

Legal References

Minnesota Statutes, 256B.0653 (Home Health Agency Services)
Minnesota Statutes, 256B.0625, subdivision 19c (Personal Care)
Minnesota Statutes, 256B.0659, subdivisions 13 and 14 (Qualified Professional; Qualifications and Duties)