Personal Care Assistant (PCA) Provider Enrollment

Personal Care Assistant (PCA) Provider Enrollment DHS is the way that Personal Care Assistant Agencies are able to bill for Medicaid with their clients through the Minnesota Department of Human Services.  In Minnesota, Medicaid is called “Medical Assistance”. All providers must meet certain qualifications in order to enroll, but as long as you have all the qualifying information, your application cannot be rejected. 

Initial Enrollment requires owners, managing employees and qualified professionals (generally a registered nurse) to attend PCA agency training before completing the enrollment process. Register for these classes now, because they fill up quickly and are often booked solid months in advance. Below is a highlight of the legal and healthcare information required to start an agency. This process can be overwhelming, which is why it is useful to engage a competent attorney who has been through the process many times. 

PCA Providers must follow these steps:

  • 1. Attend the training PCA Steps for Success.
  • 2. Pay the application fee
  • 3. Complete and submit the following information and documents to apply as a PCPO/PCA Choice provider agency.

**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.

Per the MHCP Provider Agreement (4138), the PCA Provider agrees to the following:

1. Furnish DHS, the Secretary of the U.S. Department of Health and Human Services (DHHS), or the Minnesota
Medicaid Fraud Control Unit (MFCU) with such information as it may request regarding payments claimed for
services provided under these programs.

2. Comply with all federal and state statutes and rules relating to the delivery of services to individuals and to the
submission of claims for such services.

3. Provide to DHS its National Provider Identifier (NPI) and include its NPI on all claims, if Provider is eligible for an
NPI.

4. Comply with all provisions of Minnesota Statutes 62J.536, which requires electronic transmission of claims, eligibility
and other transactions, using DHS’ secure, HIPAA-compliant, automated transaction tool MN-ITS.

5. Accept as payment in full, amounts paid in accordance with schedules established by DHS, except where payment by
the recipient has been authorized by DHS.

6. Enroll in electronic funds transfer (EFT) if Provider is a pay-to provider and if requested by DHS.

7. Ensure, when required by law, that a health service program administered by DHS is the payer of last resort by
ascertaining the legal and financial liabilities of third parties to pay for covered services, and pursuing such third party
payments.

8. Assume full responsibility for the accuracy of claims submitted to DHS in accordance with the certification
requirements of 42 CFR 455.18 and Minnesota Statutes 256B.27, subd. 2.

9. Submit claims at no more than Provider’s usual and customary fee to the general public and only after the medical
care or service has been provided, in accordance with Minnesota Rules 9505.0450, subp. 1.

10. Except for claims for services under a waiver program, submit claims only for services, supplies, and equipment that
are medically necessary as defined at Minnesota Rules 9505.0175, subp. 25, and that meet professionally recognized
standards of health care, that Provider knows or has reason to know are properly reimbursable under federal and state
statutes and rules.

11. Make full disclosure of ownership and control information as required by 42 CFR 455.100 – 455.106, and upon
request, full disclosure of business transactions, as is required by 42 CFR 455.105.

12. Make full disclosure of persons convicted of program crimes as required by 42 CFR 455.106.

13. Ensure that Provider, all of its owners, managers, employees and contractors are not excluded from participation in
Medicare, Medicaid or other federal health care programs, by searching the Office of Inspector General List of
Excluded Individuals/Entities (LEIE) at the time of enrollment, before hiring new employees or entering into a
contract with a contractor, and monthly to see changes since the last search. Provider must immediately report any
exclusion information discovered to DHS.

14. Verify recipient eligibility before rendering services.

15. Comply with all federal statutes, implementing regulations and guidance prohibiting discrimination on the basis of
race, color, national origin, sex, age, religion and disability in any program or activity receiving federal financial
assistance from DHHS.

16. Render to recipients services of the same scope and quality as would be provided to the general public, within MHCP
guidelines, in accordance with Section 1902(a)(10)(B) – (E) of the Social Security Act.

17. Comply with the provisions of any fully executed addendum required by DHS, which is incorporated with the
provider agreement (that is, the addendum becomes part of the original provider agreement).

18. Ensure that its employees and contractors comply with all MHCP requirements, including any requirements added
post-enrollment.

19. Comply with the advance directive requirements if provider is a hospital, nursing facility, provider of home health
care, personal care assistance services, hospice, or managed care organization (MCO), as required by 42 CFR 489.102
and 417.436.

20. Maintain records that fully disclose the extent of services provided to MHCP recipients for a period of five years after
the initial date of billing DHS, in accordance with Minnesota Rules 9505.2160 – 9505.2245, or for the duration of
contested case proceedings, whichever is longer.

21. Ensure proper handling and safeguarding by provider employees, contractors, and authorized agents of protected
information collected, created, used, maintained, or disclosed on behalf of DHS. For the purposes of this Agreement,
“protected information” means data subject to any of the laws described below in 21.A. This responsibility includes:
A. Ensuring that employees and agents of the provider comply with and are properly trained about:

(1) The Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes Chapter 13, in particular
13.46 Welfare Data;

(2) The Minnesota Medical Records Act, Minnesota Statutes 144.291 – 144.298;

(3) The federal Health Insurance Portability and Accountability Act (HIPAA), including but not limited to the
requirements of the Privacy Rule and Security Regulations, 45 CFR 160 and 164;

(4) Federal law and regulations that govern the use and disclosure of substance abuse treatment records, 42 USC
Sec.290dd-2 and 42 CFR 2.1 – 2.67; and

(5) Any other applicable state and federal statutes, rules, and regulations affecting the collection, storage, use and
dissemination of private or confidential information.

 

B. Ensuring, consistent with the laws stated in 21.A, that the provider’s employees, contractors, and authorized agents:

(1) Do not use or further disclose protected information created, collected, received, stored, used, maintained or
disseminated in the course or performance of this Agreement other than as necessary to perform their
obligations under this Agreement, or as required by law, either during the period of this Agreement or
thereafter (respectively, 45 CFR 164.502(b) and 164.514(d), and Minnesota Statutes 13.05, subd. 3).

(2) Use appropriate administrative, physical, and technical safeguards to prevent use or disclosure of the
protected information other than as provided for by this Agreement and to ensure the confidentiality,
integrity, and availability of any protected health information that it creates, receives, maintains, or transmits
on behalf of DHS.

(3) Do not transmit PHI over the internet or any other unsecure or open communication channel unless such
information is encrypted or otherwise safeguarded using procedures no less stringent than those described in
45 CFR 164.312. If the provider stores or maintains PHI in encrypted form, provider shall, at DHS’ request promptly provide DHS with the key or keys to decrypt such information. Provider shall not forward previously encrypted data to any other party, unless otherwise required by this Agreement.

(4) Mitigate, to the extent practicable, any harmful effects known to provider of a use, disclosure, or breach of
security with respect to protected information by provider in violation of this Agreement.

(5) Make the required notifications upon discovery of a breach, as defined in 45 CFR 164.402, of unsecured PHI
to DHS, to each individual whose unsecured PHI has been breached, and, when the breach involves the
unsecured PHI of more than 500 people, to the media of a state or jurisdiction. See 45 CFR 164.400 – 414. 

22. Accept and be bound by the terms and conditions of DHS’ EDI Trading Partner Agreement when billing
electronically. Provider acknowledges that any organization or individual that submits claims on its behalf will abide
by the EDI Trading Partner Agreement as an agent of provider. Provider authorizes the agent to bind provider to the
terms of the EDI Trading Partner Agreement. Provider will give each EDI trading partner an individual login ID and
password.

23. For provider entities receiving or making Medicaid payments totaling at least $5 million annually, establish written
policies and procedures for the education of all employees, contractors and agents, that includes information about the
False Claims Act and other provisions named in Section 1902(a)(68)(A) of the Social Security Act.

24. Determine the applicability to provider of any other state or federal laws and ensure compliance with those laws.

25. Cooperate with DHS audit procedures.

26. Execute any required Assurance Statements and provide certification or licensure information if required by DHS for
a particular provider type. Provider also agrees to notify DHS of any changes to its certification or licensure status.

27. Comply with Minnesota Statutes 256B.0644 as a requirement of participation in other state health care programs.
Provider agrees to provide active caseload data upon DHS’ request and at least 10 days before limiting acceptance of
new MHCP recipients.

28. Refund any overpayments made to provider by DHS, including those resulting from payments made by Medicare,
third party payers, billing errors, fraudulent billing, and from increased interim payments made pursuant to DHS’ plan
for continuity of operations during times of pandemic and crisis.

29. Notify DHS no later than 30 days before the effective dater of a sale, merger, or transfer of an enrolled entity, in
accordance with Minnesota Rules 9505.0195, subp. 8. Failure to notify DHS may result in the sale or transfer not
becoming effective with DHS for any purpose, including claims processing, payment of claims and claims
adjustments. Provider also agrees to notify DHS whether it intends to transfer its National Provider Identifier (NPI) or
its Federal Employer Identification Number (FEIN) to the new owner and to complete any documentation or addenda
DHS requires, including a Provider Entity Sale or Transfer Addendum. Provider acknowledges that upon sale, merger
or transfer of the enrolled entity, DHS will recognize the effective date of the sale or transfer as the date from which all
claims payments or adjustments will be assigned to the new owner, without regard to date of service, date of
submission to DHS, or adjudication date, including those resulting from a later audit or reprocessed claims. Any
intent on the part of the provider or purchaser to the contrary must be addressed in the purchase agreement and
transfer documents and is the responsibility of provider and purchaser to enforce. DHS retains the right to pursue
monetary recovery, or civil or criminal actions against the seller or transferor. Nothing in this Agreement negates the
obligation of the new owner to contact DHS by the effective date of sale, merger or transfer

These are just a highlight of the rules required to start a PCA agency. Holt Law provides representation in this area for a reasonable flat fee.

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