All non-contracted providers are encouraged to be 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) (external link).
Non-contracted providers must submit electronic 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. Failure to complete the required forms will result in your claims being rejected/denied. Please allow 15 business days between submitting the required information and submitting your electronic claim. If you receive a claim rejection/denial prior to submitting the required forms, you must resubmit your rejected/denied claim.
|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:
|W-9 ||W-9 (pdf)|
|NPI/UMPI Notification Form||5071 (pdf)|
|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.
|Provider Assurance Statement for Telehealth|
Only for eligible providers who meet the MHCP definition to provide Telehealth Services.
|Non-Contracted Provider Address Change Form|
This form is for non-contracted provider address changes only!
|Waiver of Liability Form|
Must be sent with claim reconsideration/appeal.
|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 firstname.lastname@example.org.
Web Form (external link)
Denial of Payment
Non-Contracted providers have the right to file a reconsideration/appeal 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: 1-888-633-4057
*If you have any questions on this process, the Provider Contact Center is available to providers Monday through Friday from 8 a.m. to 4:30 p.m. The toll-free number is 1-888-633-4055