Non-Contracted Providers

Non-Contracted Providers

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.

Form Name 
Non-Contracted Provider Facility Information Form 4402 (pdf)

  • 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)
Electronic Funds Transfer (EFT) Authorization AgreementWeb Form (external link)
Electronic Remittance Advice (ERA) Authorization AgreementWeb 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 Application5078 (doc)
>Web Form

Last Updated on 07/14/2021 by Nikita Woltersen

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