Forms for providers

MHP offers many of the forms required to provide services to our members. Click the category below to find the form you need.

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Claims and compliance

Claims

Denial, Termination, Reduction Recommendation (DTR) (DOC)

Claim Adjustment-Reconsideration Request (PDF)

Electronic claims

Automated Clearinghouse ACH Funds Transfer Request (PDF)

Electronic Remittance Advice Registration (coming soon)

Availability Electronic Remittance Advice Enrollment (coming soon)

Non-participating provider claim submission

Non-Contracted Provider Claim Information (PDF)

Condensed Provider Information Form (coming soon)

Form W-9 (coming soon)

Substitute W-9 Form (DOC)

Compliance

Fraud, Waste, and Abuse Training Attestation (PDF)

Contracting and credentialing

Contracting

Provider Contract Request (PDF)

Provider Information Form (PDF)

Choose your provider service type from the list below. Complete and attach it with your provider professional Information form (PIF)

Disclosure of Ownership, Business Transactions, and Exclusions Statement (coming soon)
Form W-9
(coming soon)

Substitute W-9 Form (DOC)
Providers Universal Change Request (coming soon)

Credentialing

NPI Submission (coming soon)

Minnesota Uniform Credentialing (coming soon)

Minnesota Uniform Practitioner Change (DOC)

Minnesota Uniform Reappointment Application (DOC)

Forms

Service Authorizations

Credentialing Forms

Case Management Forms

Targeted Case Management

Formulary Forms

Provider Operation Forms

Mental and chemical health services

Mental health services

Diagnostic assessment (DOC)

Day Treatment Partial Hospitalization - Adult (coming soon)

Day Treatment Partial Hospitalization - Child (coming soon)

Behavioral Health Concurrent Review - Adult (DOC)

Behavioral Health Concurrent Review - Child (DOC)

Neuropsychological Testing - Adult (DOC)

Neuropsychological Testing - Child (DOC)

Psychological Testing (DOC)

Day Treatment Service Authorization (coming soon)

Mental health targeted case management notification (PDF)

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Edited: 12/04/2013 by CMS submitted pending approval

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