Forms

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 your are a NON-CONTRACTED provider, authorizations and claims will not process until you complete the provider forms found on the Non-Contracted Providers page.

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)
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.
>5457 (pdf)
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Web Form

Notifications

Form Name & Description Form
Inpatient Admit & Discharge Notification Form
Used when providing notification of an admission or discharge of an acute care hospitalization.
4492 (pdf)
Nursing Facility (NF) Communication Form and Instructions
Used for notification of admission to a Nursing Facility.
DHS-4461-ENG (pdf)
Critical Access Hospital Swing Bed Notification Form
Used for notification of admission to a Swing Bed.
4495 (pdf)
DSD and CADI Only Waiver Recommendation for Action Denial, Termination, or Reduction (DTR) Form
Used for notification of a denial, termination, or reduction of DSD or CADI waiver services.
5208 (pdf)
Hospice Notification Form
4735 (doc)

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 ACT, Youth ACT, IRTS, CMHRTS, Partial Hospitalization, or PRTF services.
4398 (pdf)
Behavioral Health Authorization Form
Used when requesting prior authorization for Adult Day Treatment, ARMHS (after threshold is met), Certified Peer Specialist (after threshold is met), Adult Crisis Response Services–Residential Crisis Stabilization, Intensive Outpatient Mental Health Treatment (after threshold is met), Partial Hospitalization (after threshold is met), and Psychotherapy (after threshold is met).
4381 (pdf)
Request for Psychological Testing Authorization Form
Used to request Neuropsychological Testing or Psychological Testing after threshold is met.
4395 (pdf)
Behavioral Health Hospitalization Inpatient Admit & Discharge Notification
Used to notify South Country of a member’s admission to, and discharge from, a psychiatric facility. This form can also be used for inpatient SUD treatment within a hospital facility.
5116 (pdf)
MH-TCM
Form Name & Description Form
MH-TCM Eligibility Notification Form
Used when requesting MH-TCM services.
4532 (pdf)
MH-TCM Adult Diagnostic Verification Form DHS-6069A-ENG (DHS Web Form)
MH-TCM Child/Adolescent Diagnostic Verification Form DHS-6069B-ENG (DHS Web Form)
MH-TCM DTR Recommendation for Action Form
To be submitted in addition to the MH-TCM Eligibility Determination Notification Form when a member is determined ineligible at time of request for MH-TCM services. Also to be submitted when a member is receiving MH-TCM services and services will be terminated.
4533 (doc)
CTSS

Form Name & Description Form
CTSS Authorization Form
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 Form
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) Form
Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy.
4498 (pdf)
Behavioral Health Home

Form Name & Description Form
Notification of Eligibility for Behavioral Health Home (BHH) Services DHS-4797-ENG (pdf)
Behavioral Health Home and Managed Care Roles and Responsibilities 5387 (pdf)

Substance Use Disorder
Form Name & Description Form
SUD Admission & Discharge Form
Used for chemical dependency treatment, inpatient, outpatient, methadone.
4505 (pdf)
SUD Request Worksheet (pdf)
Used by Rule 25 Assessors only.
4506 (pdf)
SUD Complexities Grid (pdf) 4507 (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
4536 (pdf)
Healthy Pathways Renewal Request or End of Service Notification Form
To be submitted by eligible case manager to renew or end the service.
5202 (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 Form/
Provider Appeals Form
4356 (doc)
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 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 Telemedicine
Only for eligible providers who meet the MHCP definition to provide Telemedicine Services.
5206 (pdf)
Non-Contracted Provider Address Change Form
This form is for non-contracted providers only!
4911 (pdf)
Waiver of Liability Form
Must be sent with claim reconsideration/appeal
4629 (doc)
Provider Contract Application 5078 (doc)
>Web Form

Contracted Providers

Form Name & Description Form
Ownership and Control Interest Disclosure Statement 3333 (pdf)
Contracted Entity Location Add/Remove Form 5079 (doc)
Contracted Entity Change Update Form 5073 (doc)
Provider Assurance Statement for Telemedicine
Only for eligible providers who meet the MHCP definition to provide Telemedicine 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
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)
Shingles Vaccine Claim Form 5546 (pdf)
Shingles Vaccine Billing Process 5545 (pdf)
Recommendation for Authorization of Home Care Services DHS-5841-ENG (pdf)
PCA Request Form 5207 (pdf)
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