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South Country Health Alliance | Non-Contracted Providers

Non-Contracted Providers

Out-of-network providers may submit claims to SCHA for reimbursement. Some services will require prior authorization. Please see the links below for more detailed information regarding provider billing and authorizations.

All out-of-network providers should complete the following forms the first time submitting claims to SCHA, or when any information on previously submitted forms has changed.

Form Name 
Non-Contracted Provider Facility Information Form 4402 (pdf)
Non-Contracted Provider Address Change Form
This form is for non-contracted providers only!
4911 (pdf)
NPI Notification Form4630 (doc)
W-9W-9 (pdf)
Electronic Funds Transfer (EFT)Authorization AgreementWeb Form
Electronic Remittance Advice (ERA) Authorization AgreementWeb Form
EFT-ERA User Guide4412 (pdf)
Waiver of Liability Form4629 (doc)
Provider Assurance Statement for Telemedicine Only for eligible providers who meet the MHCP definition to provide Telemedicine Services.5206 (pdf)

Denial of Payment

Out-of-network providers have the right to file a reconsideration request for the denial of payment within 60 calendar days from the date of your denial of payment notice. For your reconsideration request to be processed, you must agree to sign the Waiver of Liability Form (pdf). You should also include any documentation that supports your reason for requesting this reimbursement (i.e., a copy of the original claim, remittance notification showing the denial, pertinent clinical records, and any other supporting documentation to be considered).

Fax all information to: 888-633-4057