Medica Administrative Manual> Provider Responsibilities > Disclosure of Ownership and Excluded Entities

Disclosure of Ownership and Excluded Entities

The Minnesota Department of Human Services (DHS) requires Medica to ensure that its network providers meet certain obligations pertaining to disclosure of ownership interests and the provision of items and services by individuals or entities excluded from participation in government programs. These requirements are summarized below, along with the process for submitting this information to Medica on a new Disclosure Statement form.

Disclosure Statement form (DOC)

Disclosure of Ownership Interests

On an annual basis, providers must report to Medica the following information related to ownership interests:

• The name and address of each person with an ownership or control interest in the provider, or in any subcontractor in which the provider has a direct or indirect ownership of 5 percent or more;
• The name and address of each managing employee (general manager, business manager, administrator, or director) who exercises operational or managerial control over the Provider, or part thereof, or who directly or indirectly conducts the day-to- day operations of the Provider, or part thereof; and
• A statement as to whether any person with an ownership or control interest is related as a spouse, parent, child, or sibling to any other person with an ownership or control interest; and
• For a person with an ownership or control interest in the provider, the name of any organization in which the person has an additional ownership or control interest.

Note: Providers must complete and submit the Disclosure Statement form on an annual basis, whether or not they have information to report. A New Disclosure Statement must be submitted when any information in the original statement has changed.

This disclosure stems from additional requirements for disclosure by the Centers for Medicare and Medicaid Services (CMS).

View the Additional Requirements for Disclosure

Disclosure of Excluded Individuals, Entities

Providers are required to follow these steps:

1. Search the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE) database and the General Services Administration (GSA) Excluded Parties List System (EPLS) on a monthly basis to ensure that providers, agents, persons with an ownership or control interest, and managing employees (general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operations of an institution, organization or agency): (i) are not debarred, suspended or otherwise excluded from participation in Medicaid, Medicare, or any other federally funded government program; (ii) have not been convicted of a criminal offense related to that person’s or entity’s involvement in any federally funded government program; and (iii) have not been sanctioned by the OIG;
2. Assure Medica that Provider will not employ, purchase products or services from, or contract with any subcontractor who: (i) has been convicted of a criminal offense related to the individual’s or entity’s involvement in any federally funded government program; (ii) is listed as debarred, suspended or otherwise excluded from participation in any federally funded government program; or (iii) has been sanctioned by the OIG; and
3. Report to Medica within five days any information regarding individuals or entities who have been: (i) convicted of a criminal offense related to the involvement in any federally funded government program; (ii) listed as debarred, suspended or otherwise excluded from participation in any federally funded government program; or (iii) sanctioned by the OIG.

Providers are able to search the U.S. Department of Health and Human Services, and the U.S. General Services Administration databases:

• LEIE (OIG) Online Searchable Database
• LEIE (OIG) Downloadable Databases
• EPLS (SAM) Online Searchable Database
• Social Security Administration's Death Master File
• National Plan and Provider Enumeration System (NPPES)
• Excluded Provider Lists maintained by each state

Providers must submit this information to Medica using a new Disclosure Statement form through one of the following means:

• Email completed and signed forms to [email protected] (preferred method)
• Mail completed and signed forms to:

Medica Health Plans
Mail Route CP425
P.O. Box 9310
Minneapolis, MN 55440-9310

If completed document is handwritten, please print legibly or the form may be returned as incomplete.

If you have any questions, please call 1 (800) 458-5512 or send an email to the above email address.