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South Country Health Alliance | Non-Contracted Providers

Non-Contracted Providers

All Non-Contracted Providers are encouraged to enrolled with the State of Minnesota Department of Human Services, as a Minnesota Health Care Programs Provider. You can access additional information on the provider enrollment process at Information to Enroll as a Minnesota Health Care Programs (MHCP) Provider with the Minnesota Department of Human Services (DHS).

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.

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