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). MUST COMPLETE PCA STEPS FOR SUCCESS BEFORE YOU CAN APPLY. DHS IS USUALLY BOOKED OUT AT LEAST 3 MONTHS. 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. (Billing lab can only be registered for after you are approved.)
- 2. Pay the provider enrollment application fee
- 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 the Office 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 the MHCP 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) – Completed after Application is accepted, and receive NetStudy Login.)
- 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 (MUST BE COMPLETE BEFORE APPLICATION CAN BE SUBMITTED.)
- 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 when revenue is up to $50,000 – otherwise $100,000.
Legal Citation. Per Minn. Stat. 256B.0659 Subd. 21:
Requirements for provider enrollment of personal care assistance provider agencies.
(a) All personal care assistance provider agencies must provide, at the time of enrollment, reenrollment, and revalidation as a personal care assistance provider agency in a format determined by the commissioner, information and documentation that includes, but is not limited to, the following:
(1) the personal care assistance provider agency’s current contact information including address, telephone number, and e-mail address;
(2) proof of surety bond coverage. Upon new enrollment, or if the provider’s Medicaid revenue in the previous calendar year is up to and including $300,000, the provider agency must purchase a surety bond of $50,000. If the Medicaid revenue in the previous year is over $300,000, the provider agency must purchase a surety bond of $100,000. The surety bond must be in a form approved by the commissioner, must be renewed annually, and must allow for recovery of costs and fees in pursuing a claim on the bond;
(3) proof of fidelity bond coverage in the amount of $20,000;
(4) proof of workers’ compensation insurance coverage;
(5) proof of liability insurance;
(6) a description of the personal care assistance provider agency’s organization identifying the names of all owners, managing employees, staff, board of directors, and the affiliations of the directors, owners, or staff to other service providers;
(7) a copy of the personal care assistance provider agency’s written policies and procedures including: hiring of employees; training requirements; service delivery; and employee and consumer safety including process for notification and resolution of consumer grievances, identification and prevention of communicable diseases, and employee misconduct;
(8) copies of all other forms the personal care assistance provider agency uses in the course of daily business including, but not limited to:
(i) a copy of the personal care assistance provider agency’s time sheet if the time sheet varies from the standard time sheet for personal care assistance services approved by the commissioner, and a letter requesting approval of the personal care assistance provider agency’s nonstandard time sheet;
(ii) the personal care assistance provider agency’s template for the personal care assistance care plan; and
(iii) the personal care assistance provider agency’s template for the written agreement in subdivision 20 for recipients using the personal care assistance choice option, if applicable;
(9) a list of all training and classes that the personal care assistance provider agency requires of its staff providing personal care assistance services;
(10) documentation that the personal care assistance provider agency and staff have successfully completed all the training required by this section;
(11) documentation of the agency’s marketing practices;
(12) disclosure of ownership, leasing, or management of all residential properties that is used or could be used for providing home care services;
(13) documentation that the agency will use the following percentages of revenue generated from the medical assistance rate paid for personal care assistance services for employee personal care assistant wages and benefits: 72.5 percent of revenue in the personal care assistance choice option and 72.5 percent of revenue from other personal care assistance providers. The revenue generated by the qualified professional and the reasonable costs associated with the qualified professional shall not be used in making this calculation; and
(14) effective May 15, 2010, documentation that the agency does not burden recipients’ free exercise of their right to choose service providers by requiring personal care assistants to sign an agreement not to work with any particular personal care assistance recipient or for another personal care assistance provider agency after leaving the agency and that the agency is not taking action on any such agreements or requirements regardless of the date signed.
(b) Personal care assistance provider agencies shall provide the information specified in paragraph (a) to the commissioner at the time the personal care assistance provider agency enrolls as a vendor or upon request from the commissioner. The commissioner shall collect the information specified in paragraph (a) from all personal care assistance providers beginning July 1, 2009.
(c) All personal care assistance provider agencies shall require all employees in management and supervisory positions and owners of the agency who are active in the day-to-day management and operations of the agency to complete mandatory training as determined by the commissioner before enrollment of the agency as a provider. Employees in management and supervisory positions and owners who are active in the day-to-day operations of an agency who have completed the required training as an employee with a personal care assistance provider agency do not need to repeat the required training if they are hired by another agency, if they have completed the training within the past three years. By September 1, 2010, the required training must be available with meaningful access according to title VI of the Civil Rights Act and federal regulations adopted under that law or any guidance from the United States Health and Human Services Department. The required training must be available online or by electronic remote connection. The required training must provide for competency testing. Personal care assistance provider agency billing staff shall complete training about personal care assistance program financial management. This training is effective July 1, 2009. Any personal care assistance provider agency enrolled before that date shall, if it has not already, complete the provider training within 18 months of July 1, 2009. Any new owners or employees in management and supervisory positions involved in the day-to-day operations are required to complete mandatory training as a requisite of working for the agency. Personal care assistance provider agencies certified for participation in Medicare as home health agencies are exempt from the training required in this subdivision. When available, Medicare-certified home health agency owners, supervisors, or managers must successfully complete the competency test.
**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.