Below are forms for providers.
Use this form to set up and authorize electronic fund transfers between Hennepin County and your financial institution.
Complete this form to receive electronic remittance advice (835) files electronically through Availity Health Information Network.
Fill out these forms if you are interested in becoming an MHP contracted provider.
This form should be submitted when you have additional or corrected data that should have been submitted on the original claim or to request a reconsideration of a previously adjudicated claim that does not require additional information.
Complete this form to determine a place of service for mental health or chemical dependency treatment.
Every provider must complete and submit these regulatory forms for credentialing. Credentialing forms must be resubmitted every three years to ensure MHP records are up to date.
Complete this form to request additional units beyond two per calendar year.
This form is to be completed per contract requirements for: (1) disclosure of ownership; (2) exclusions of individuals and entities from government programs as set forth in each of the health plan’s administrative requirements; and 3) significant business transactions.
To appeal the denial of a prescription, complete and submit this form. This request should be submitted with any previous and new information for a second-level review.
This referral form is for specialty services not available within the Hennepin Health network and should be used by Hennepin Health partner providers only (HCMC clinics or NorthPoint Health & Wellness Center).
Complete this form and include any relevant medical documentation to request authorization to perform services during an inpatient stay.
To ensure proper payment to the referral provider, the primary care physician must send this referral form to MHP.
MHP Mental Health Targeted Case Management (MH-TCM) providers are required to submit a notification form at the following times:• Prior to delivery of MH-TCM services• When the MH-TCM case is closed• When MH-TCM services end through MHP• When the MH-TCM case manager changes within the same agency
Complete this form to request an authorization for benefits above the threshold of eight units per year.
If you need information regarding a MHP member, complete this form with the member and submit it to MHP.
Complete this form if you would like to prescribe a drug that is not available in the MHP formulary.
Complete this form to appeal the denial of a prescription. The request should be submitted with any previous and new information for a second-level review.
This form should be completed if you do not agree with how your claim was processed.
Use this form to inform MHP of any demographic additions or changes made to your clinic.
To ensure accurate claims processing and payment, non-contracted providers need to complete and submit this form.
According to MN Rules 4685.1110 and 4685.1900, providers are required to report verbal and/or written complaints that originate at the provider level to the member’s health plan. Quality of care and service complaints directed to the medical group are to be investigated and resolved by the medical group.
Complete this form to request an authorization for benefits above the threshold of eight tests per year.
Complete this form as a referral for personal care assistance services and send back to the member's county.
Refer to this grid when admitting a Cornerstone Solutions member into a nursing facility.
To request authorization to perform services, complete this form and include any relevant medical documentation.
Complete this form to document any transition of care such as a hospital admission or discharge.
Contracted providers need to complete this form that now includes a section for required affirmative action information.
Non-contracted providers need to complete this form.