Claims

Forms

Form Name & DescriptionForm
Claim Reconsideration Form/
Provider Appeals Form

-------Important Update!-------
We are transitioning to an electronic claim appeal submission. Starting April 1, 2023, this Word form will no longer be available. You will be 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.
4356 (doc)
Provider Adjustment Request Form4357 (pdf)
Attachment Cover Sheet4349 (doc)
Claims Error Codes & Descriptions
Troubleshooting help
5584 (pdf)

Submission Information

Use the chart below to find information for South Country Health Alliance claims submission. For pharmacy claims, see
Pharmacy.

ServiceSubmission Information
Medical/Behavioral Health Services or ChiropracticSCHA Provider Portal (website)
1-888-633-4055
Payer Identification Number - 81600
Dental ServicesDelta Dental of Minnesota
P.O. Box 9120
Farmington Hills, MI 48333-9120
1-866-398-9419
Payer Identification Number - 07000

 

Minnesota Uniform Companion Guides
The Administrative Uniformity Committee (AUC) provides common billing practices for Minnesota payers and providers. The companion guides help determine the most appropriate practices for your agency/facility.

Minnesota Uniform Companion Guides (external website)

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