Non-participating providers must apply for network participation by completing the 3715 Provider Contract Application (doc). The South Country Health Alliance Provider Network Department will review your application and respond with a determination.
Please note that submitting a credentialing application is NOT a contract for provider participation.
South Country Health Alliance is partnered with the Minnesota Credentialing Collaborative (MCC) and ApplySmart in order to offer providers a streamlined option for submitting credentialing applications. By enrolling with MCC, providers can access and use a centralized, Web-based clearinghouse for information used for the credentialing process. The online product is an easy to use way to prepare, save, and send the credentialing application accepted by participating Minnesota Health Plans, hospitals, clinics, and practitioners. Visit www.mncred.org for more information.
South Country Health Alliance encourages practitioners to complete the credentialing process using the MCC/ApplySmart system. If this is not an option, applications may be submitted via email to firstname.lastname@example.org. Applicable credentialing documents may be found below. Faxed and hard copy submissions will be returned unprocessed.
- Minnesota Uniform Credentialing Application – Initial (pdf)
- Minnesota Uniform Credentialing Application – Reappointment (pdf)
- MN Uniform Practitioner Change Form (doc)
- 4142 Organizational Credentialing Assessment Form (pdf)
- Model of Care Summary – Provider Edition (pdf)
Credentialing Tips for More Efficient Application Processing
- Credentialing applications should be submitted at least 90 days prior to the practitioner’s start date with your organization as South Country Health Alliance does not assign retroactive effective dates.
- All applicable sections of the credentialing application must be completed, including the Model of Care Summary.
- Include an email address to receive important communications from South Country Health Alliance.
- Include additional languages you fluently speak.
- Include start date, if accepting new patients, and if you’d like to be suppressed from South Country Health Alliance’s provider directories for each practice location.
- State the specialty you currently provide to South Country Health Alliance members in the Primary Specialty field. If also providing a secondary/tertiary specialty, please state in the Sub Specialty field.
- All date fields must be in month, day, and year format.
- Explain employment gaps longer than 3 months.
- If no hospital admitting privileges, please describe coverage for continuity of care.
- Professional references must have personal knowledge of your current (within past 12 months) clinical skills, abilities, judgment, professional performance, and clinical competence or have been responsible for professional observation or your work (limit to 1 current office associate). Do not include your residency or fellowship director, relatives, or pending partners. At least 1 reference should be in your specialty/subspecialty.
- Enter an affirmative response and detailed explanation to all applicable Disclosure Questions.
- Updating the Attestation Signature does not update the Authorization Release or Application Addendum. You must also update these pages when updating your application.
- Include a Malpractice Litigation Addendum for each issue reported in your application.
- Include current copies of applicable professional state licensure, DEA registration, and malpractice liability insurance certificate.
- All signatures and dates must be clearly legible or signed with a unique electronic identifier within 30 days of submission to South Country Health Alliance.
Rights and Notification
- Practitioners shall have the right, upon written request, to review their credentialing file except for information that is privileged or protected from such disclosure and to submit corrective statements with respect to the initial application. South Country Health Alliance or its TPA will place the corrective statement in the practitioner’s credentialing file, but this does not require South Country Health Alliance or its TPA to alter or delete any information contained in the file.
- Practitioners shall be informed of any information discrepancies and shall have the opportunity to correct erroneous information gathered during the credentialing process, prior to review by the South Country Health Alliance Credentialing Committee.
- Practitioners, upon request, shall be informed of the status of their credentialing or recredentialing application.
Application and change form submissions: email@example.com
Credentialing questions/concerns/application status updates: firstname.lastname@example.org