Minn. R. 4688.0020 - APPLICATION
An application for ECP designation shall be made on forms provided by the commissioner. The applicant shall provide all of the information described in items A to G.
A. The name of the applicant's contact person
and that person's address and telephone number.
B. The applicant's status as either:
(1) a local government unit, an Indian tribal
government, the Indian Health Service, a service unit or facility, or a
community health board; or
(2)
evidence of Minnesota Statutes, chapter 317A, nonprofit status, Internal
Revenue Code, section 501(c)(3), tax exempt status, a copy of the applicant's
current sliding fee schedule, and evidence that the applicant does not restrict
access or services because of the client's financial limitation.
C. A list of medical services
provided, by Current Procedural Terminology 95 (CPT 95) codes or categories of
Current Procedural Terminology 95 (CPT 95) codes.
D. Evidence of the applicant's capacity to
provide medical services in a timely manner consistent with community norms,
including the number and type of health professionals available and the
applicant's appointment scheduling guidelines and procedures.
E. A list of which of the following
populations the applicant serves: uninsured persons, high risk and special
needs populations, and underserved and other special needs populations. In
addition, the applicant must provide:
(1) the
total number of clients falling within the populations served annually;
and
(2) what percent of the
applicant's total patient population falls within those populations.
F. A list of supportive and
stabilizing services available including an explanation of how the need for
services is assessed, how clients access the services, how these services are
made available to clients in need of such services, and to what extent these
services are used by clients. If specific supportive and stabilizing services
are not available, an explanation of why the following services are unavailable
or inappropriate for the specific populations served by the applicant:
(1) transportation;
(2) child care;
(3) linguistic services;
(4) culturally sensitive and competent
services; and
(5) other supportive
and stabilizing services.
G. Any other information requested by the
commissioner that is reasonably necessary to determine whether the application
should be granted or denied.
Notes
Statutory Authority: MS s 62Q.19
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