Your initial PCA Application (PCPO or PCA Choice) must include all items listed below. Any additional business sites or locations must also submit a complete application.
First, you will need to get:
- Your Business Entity registered with the Minnesota Secretary of State ($155 online filing fee, instant filing) Online here.
- Your Federal Employer Identification Number (free) Online here.
- Your Minnesota Tax Id (free) Online here.
- Your National Provider Identification Number (free) Online here.
PCPO and PCA Choice providers must follow these steps:
- 1. Have your Owners, Managing Employees and Qualified Professionals attend the training PCA Steps for Success. (currently $95 per person, 3 day training, which may be done online, but I recommend in person). Register here online. Keep copies of the certificates. Also have your PCA Billing Designated person complete the PCA Billing Labs training AFTER you are approved as an enrolled provider. Register here online.
- 2. Pay theprovider enrollment application fee (current ~$560)
- 3. Complete and submit the following information and documents to apply as a PCPO/PCA Choice provider agency.
- MHCP PCPO/PCA Choice Agency Enrollment Application (DHS-4022) (PDF)
- Enter all agency personnel into theOffice of Inspector General (OIG) Exclusion list to verify they are not on the list
- Verify to ensure any individual or entity identified on the Disclosure of Ownership form (DHS-5259) or any other employees are not on theMHCP Enrolled Provider Excluded Provider Lists as an excluded group or individual provider
- Disclosure of Ownership and Control Interest (DHS-5259) (PDF)
- Qualified Professional (QP) Acknowledgement (DHS-4022C) (PDF)
- Complete Background Studies for All Owners and Qualified Professional (see Instructions for DHS Background Studies (Included with DHS-4022)
- Request for Licensing Agency ID Number (included with DHS-4022)
- 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)
- PCA Agency Personnel List and Affiliation(s) (DHS-6041)
- 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 Applicant 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 MHCP 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 initial enrollment process above.