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||4402 (pdf)|
|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 Telemedicine|
Only for eligible providers who meet the MHCP definition to provide Telemedicine Services.
|Non-Contracted Provider Address Change Form|
This form is for non-contracted providers only!
|Waiver of Liability Form|
Must be sent with claim reconsideration/appeal
|Provider Contract Application||5078 (doc)