Non-Contracted providers may submit claims to South Country Health Alliance (South Country) for reimbursement. Some services will require prior authorization. Please see the links below for more detailed information regarding provider billing and authorizations.
All Non-Contracted providers must complete the following forms prior to submitting claims to South Country, or when any information on previously submitted forms has changed.
|Non-Contracted Provider Facility Information Form||4402 (pdf)|
|Non-Contracted Provider Address Change Form|
This form is for non-contracted providers only!
|NPI Notification Form||4630 (doc)|
|Electronic Funds Transfer (EFT)Authorization Agreement||Web Form|
|Electronic Remittance Advice (ERA) Authorization Agreement||Web Form|
|EFT-ERA User Guide||4412 (pdf)|
|Waiver of Liability Form||4629 (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).