Medicare Part D: The Medicare prescription drug benefit program. We call this program “Part D” for short. Medicare Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Medicare Part B or Medical Assistance. Our plan includes Medicare Part D.Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that covers services (such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.Medical Assistance: This is the name of Minnesota’s Medicaid program. Medical Assistance is run by the state and is paid for by the state and the federal government. It helps people with limited incomes and resources pay for long-term services and supports and medical costs.
It covers extra services and some drugs not covered by Medicare. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Forms

Can’t find a form on this page? Try the looking in the provider portal. The portal has several provider forms, including credentialing forms, authorization forms and other provider network forms.
If you are a NON-CONTRACTED provider, authorizations and claims will not process until you complete the provider forms found on the Non-Contracted Providers page.
If you are having difficulty opening a form, click on FORMS HELP.

Forms Help

Authorizations

Form Name & Description Form
Medical Services Request Form
Use this form when requesting authorization for medical/surgical services, DME, and out-of-network requests.		 4497 (pdf)
Early Intensive Developmental and Behavior Intervention (EIDBI) Authorization
Used to request authorization for EIDBI services. The form can also be used to request prior authorization for EIDBI services after the threshold has been met.		 4894 (pdf)
Inpatient Authorization Request
Use this form when requesting authorization outside of Minnesota, North Dakota, South Dakota, Iowa and Wisconsin.		 4494 (pdf)
Medical Pharmacy Request
Use this form when requesting authorization for Medical Pharmacy. Medical Pharmacy generally refers to drugs that are injected or infused by a health care professional in the doctor’s office, infusion center or hospital outpatient. 		4493 (pdf)
Private Room Authorization Request
Use this form when requesting authorization of a private room in a nursing facility.		 4496 (pdf)
Managed Care Referral Request Form
ONLY use this form for Restricted Recipient Program (RRP) members. This form is utilized for RRP members which requires a member's primary care provider to submit a referral for all specialists.		 >6226 (pdf)
>Web Form

Notifications

Form Name & Description Form
Inpatient Admission & Discharge Notification
Used when providing notification of an admission or discharge of an acute care hospitalization.		 4492 (pdf)
Behavioral Health Hospitalization Inpatient Admission & Discharge Notification
Providers within the 5-state area (MN, ND, SD, WI, IA) use this notification form for a behavioral health admission and discharge from a psychiatric facility or mental/behavioral health unit.		 5116 (pdf)
Nursing Facility (NF) Communication Form and Instructions
Used for notification of admission to a Nursing Facility.		 DHS-4461-ENG (pdf) download only
Critical Access Hospital Swing Bed Notification Form
Used for notification of admission to a Swing Bed.		 4495 (pdf)
Managed Care Organization, County Agency and Tribal Nation Communication Form - Recommendation for State Plan Home Care Services (DHS‑5841)
This PDF will not open in your browser. Instead, download the PDF and open it with Adobe Reader or Acrobat. The downloaded file will be named "form.pdf."		 DHS-5841 (pdf) download only
Hospice Notification Form
 4735 (pdf)

Behavioral Health

Choose the form type below

Behavioral Health Notification & Authorization (applies to multiple services)

Form Name & Description Form
Initial Behavioral Health Notification
Used to provide notification of IRTS, CMHRTS, Partial Hospitalization or PRTF services.		 4398 (pdf)
Behavioral Health Authorization
Use this form when requesting prior authorization for behavioral health services that exceed threshold. IE: Adult Day Treatment, ARMHS, PHP, IOP, etc.		 4381 (pdf)
Psychological Testing Authorization
Use this form to request Neuropsychological Testing or Psychological Testing after threshold is met.		 4395 (pdf)
Behavioral Health Hospitalization Inpatient Admission & Discharge Notification
Providers within the 5-state area (MN, ND, SD, WI, IA) use this notification form for a behavioral health admission and discharge from a psychiatric facility or mental/behavioral health unit.		 5116 (pdf)
MH-TCM
Form Name & Description Form
MH-TCM Notification Form
Used when requesting MH-TCM services.		 4532 (pdf)
MH-TCM Adult Diagnostic Verification Form DHS-6069A-ENG (pdf) download only
MH-TCM Child/Adolescent Diagnostic Verification Form DHS-6069B-ENG (pdf)
MH-TCM Notification of Denial or Termination
Use this form when a member is receiving MH-TCM services and services will be terminated or determined ineligible at time of request for MH-TCM services.		 4533 (pdf)

CTSS

Form Name & Description Form
Children’s Therapeutic Services and Supports (CTSS) Authorization
Used when requesting prior authorization for a CTSS services (crisis assistance, family therapy, group therapy, multi-family group, therapy) after threshold is met.		 4390 (pdf)

EIDBI

Form Name & Description Form
Early Intensive Developmental and Behavior Intervention (EIDBI) Authorization
Used to request authorization for EIDBI services. The form can also be used to request prior authorization for EIDBI services after the threshold has been met.		 4894 (pdf)
DBT

Form Name & Description Form
Dialectic Behavior Therapy (DBT) Authorization
Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy.		 4498 (pdf)
Behavioral Health Home - Fax BHH Notification of Eligibility form to (507) 431-6329

Form Name & Description Form

Notification of Eligibility for Behavioral Health Home (BHH) Services
Fax BHH Notification of Eligibility Form to (507)- 431-6329

 DHS-4797-ENG (pdf)
Behavioral Health Home and Managed Care Roles and Responsibilities 6715 (pdf)

Substance Use Disorder
Form Name & Description Form
SUD Residential Admission & Discharge Notification
Used for inpatient substance use disorder treatment within the surrounding 5 state area (MN, IA, WI, ND, SD).		 4505 (pdf)
Out of Network SUD Authorization
Used for outpatient (H2035) substance use disorder treatment for providers that are outside of the state of Minnesota. Also used for inpatient (H2036) substance use disorder treatment providers outside the 5 state area (MN, IA, WI, ND, SD).		 5991 (pdf)
Healthy Pathways

Healthy Pathways is a program to assist members in preventing mental health deterioration through early intervention and education. This program can also be used as a transition service for those requiring a maintenance level of service or for members who qualify for MH-TCM but opt to use an alternative service instead. Please utilize the following forms to request this service.

Form Name & Description Form
Healthy Pathways Initial Request Form
To be submitted by eligible case manager to initiate, change, renew, or end the service		 6021 (pdf)
Healthy Pathways Renewal Request or End of Service Notification Form
To be submitted by eligible case manager to renew or end the service.		 6023 (pdf)
Healthy Pathways Program Criteria & Process 5228 (pdf)
Healthy Pathways Provider Billing Process 5227 (pdf)

Diagnostic Assessment Resources
Form Name & Description Form
Diagnostic Assessment (DA) Report Components DA Report Components (external website)
Standard Diagnostic Assessment (DA) Tool Standard Diagnostic Assessment (DA) Tool (doc)

Medication Reconciliation

Form Name & Description Form
Guide to Billing Medication Reconciliation 4595 (pdf)
Medication Reconciliation Tool 4547 (pdf)
Personal Health Record 4548 (pdf)

Claims

Form Name & Description Form
Claim Reconsideration/Provider Appeals
-------Important Update!-------
Providers are required to submit your claim appeal electronically on our Provider Portal by selecting “Forms & Resources” then “Provider Appeal Form.” Call the Provider Contact Center at 1-888-633-4055 with any questions.		 This form is no longer available.
Provider Adjustment Request Form 4357 (pdf)
Attachment Cover Sheet 4349 (doc)
Claims Error Codes & Descriptions
Troubleshooting help		 5584 (pdf)

Non-Contracted Providers

Form Name
REQUIRED NON-CONTRACTED FORMS TO ALLOW CLAIMS ADJUDICATION ARE:
Non-Contracted Provider Facility Information Form
For Non-Contracted Providers only. Please complete this form if:

  • You are new to South Country, this is your first-time billing South Country and do not want to become a contracted Provider with South Country at this time.

  • You have completed a contracted application to become a South Country Provider and your application is still pending.

  • You are reporting a change or updating your file with South Country as it may have changed since you last completed this form. (Please note - if you are updating your address only, please complete the Non-contracted Provider Address Change Form below.)

 4402 (pdf)
W-9

  • When submitting an Employer Identification Number (EIN) the name must be entered in Box 1 the same as it was registered with the IRS when the EIN was assigned.

  • When submitting a Social Security Number (SSN), only the name of the person assigned to that SSN should be Box 1 with the last name, first name and middle initial.

  • Only an EIN or SSN can be listed in Part 1, you cannot list both.

 W-9 (pdf)
NPI/UMPI Notification Form

  • The Social Security Number is required by the State of Minnesota for reporting purposes only.

  • If your claim requires a referring or ordering provider, please verify that the provider is eligible to refer or order.

  • If the services are Medicare-covered, the referring/ordering provider needs to be enrolled with the Centers for Medicare & Medicaid Services (CMS) or have opted out of enrollment with CMS. (If the provider has opted out, include the affidavit with the claim.)

  • If the services are covered by Minnesota Medical Assistance (Medicaid), the referring/ordering provider information will be added to the Minnesota Health Care Programs (MHCP) provider database.

 5071 (pdf)
ADDITIONAL FORMS/GUIDES
Electronic Funds Transfer (EFT) Authorization Agreement Web Form (external link)
Electronic Remittance Advice (ERA) Authorization Agreement Web Form (external link)
EFT-ERA User Guide
Also refer to Provider Manual Chapter 4, Provider Billing.		 4412 (pdf)
Provider Assurance Statement for Telehealth
Only for eligible providers who meet the MHCP definition to provide Telehealth Services.		 5206 (pdf)
Non-Contracted Provider Address Change Form
This form is for non-contracted provider address changes only!		 4911 (pdf)
Waiver of Liability Form
Must be sent with claim reconsideration/appeal.		 4629 (doc)
Provider Contract Application
If you are a provider who is looking to become contracted with South Country and join our network, please complete the contract application by either completing the web form or downloading the PDF version, completing it, and emailing it to providerinfo@mnscha.org.
All providers must be enrolled with Minnesota Health Care Programs (MHCP) before submitting a contract application to South Country. Please do not submit a contract application until after you have received an Enrollment or Welcome Letter/Notification from MHCP.		 Web Form and download(external link)

Contracted Providers

Form Name & Description Form
W-9

  • When submitting an Employer Identification Number (EIN) the name must be entered in Box 1 the same as it was registered with the IRS when the EIN was assigned.

  • When submitting a Social Security Number (SSN), only the name of the person assigned to that SSN should be Box 1 with the last name, first name and middle initial.

  • Only an EIN or SSN can be listed in Part 1, you cannot list both.

 W-9 (pdf)
Ownership and Control Interest Disclosure Statement
If there is an ownership change, please complete the Entity Sale or Transfer Addendum and the Ownership and Control Interest Disclosure Statement and email both to providerinfo@mnscha.org for the team to review and determine what the next steps for contracting are.		 3333 (pdf)
Add/Remove Location Form
If you are adding or removing a location from your organization, please use the Add/Remove Location form. Please include an updated W9 when adding a location.		 5079 (pdf)
Change/Update Form
If you are changing any of your information, for example, there is a mailing, billing, or physical address change, contact change, phone, or fax number, NPI, TIN, etc, please use the Change/Update Form. Please include an updated W9 with the following changes, billing address, TIN, or name change.		 5073 (pdf)
Change of Services Form
If you are changing any services at a particular location.		 Web Form
Practitioner Change/Update Form
If updates are required to a currently credentialed practitioner, please complete the Minnesota Uniform Practitioner Change Form.		 Minnesota Uniform Practitioner Change Form (pdf)
Entity Sale or Transfer Addendum
If there is an ownership change, please complete the Entity Sale or Transfer Addendum and the Ownership and Control Interest Disclosure Statement and email both to providerinfo@mnscha.org for the team to review and determine what the next steps for contracting are.		 6557 (pdf)
Provider Assurance Statement for Telehealth
Only for eligible providers who meet the MHCP definition to provide Telehealth Services.		 5206 (pdf)
Provider Quality Complaint Reporting Form 4458 (doc)
Organizational Credentialing Assessment Form 4692 (pdf)
Electronic Funds Transfer (EFT)Authorization Agreement Web Form
Electronic Remittance Advice (ERA) Authorization Agreement Web Form
EFT-ERA User Guide 4412 (pdf)

Transportation Forms

Form Name & Description Form
Minor Parental Authorization Consent Form
This form must be used when transporting any minor younger than 18 years of age without an accompanying parent or guardian.		 Consent Form (pdf)
RideConnect Brochure for Health Care Providers
A brochure for health care providers and caregivers describing the RideConnect service.		 RideConnect Brochure (pdf)
RideConnect Request Form
The form used by providers and caregivers to request non-emergency medical transportation for patients from the RideConnect service.		 Web Form
Protected Transportation Form
Complete this form for South Country Health Alliance members who have received protected transportation within 72 hours of transport.		 Protected Transportation Form (pdf)
Provider Manual Chapter 27 Provider Manual

Miscellaneous

Form Name & Description Form
Sterilization Consent Form Consent Form (pdf)
Sterilization Facts for Men Link (web)
Sterilization Facts for Women Link (web)
Medicare Part D Vaccine Claim Form 5546v3 (pdf)
Medicare Part D Vaccine Billing Process 5545v3 (pdf)
Complex Case Management Referral Form 6758 (pdf)

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