Authorizations – South Country Health Alliance

Service Authorizations

South Country Health Alliance requires prior authorization for some services, procedures, medical pharmacy (drugs) and medical devices before they can be covered. The prior authorization process consists of a review for medical necessity and a decision. The request must be approved for the member to receive the service and the claim to be paid.

Inpatient Authorizations

South Country does not require prior authorization for inpatient stays (within MN, IA, ND, SD, WI), however, we do require notification. If your facility participates in the Minnesota Encounter Alerts System (MN-EAS) you do not need to fax us a notification. If you do not participate in the MN-EAS, then please fax us the admission and discharge notifications. Find the submission forms below.

Please note: Receiving an approved prior authorization does not guarantee coverage or payment. Whether or not authorization is required depends on the member’s eligibility, product, benefit limits and medical necessity policies/criteria.

Is Prior Authorization Required?

Please use our Prior Authorization Lookup Tool to find the service/procedure/drug you are looking for to determine if a prior authorization is required. Additionally, if you scroll down you will find our prior authorization grids.

PA Lookup Tool Coming Soon

Prior Authorization Lists

Type	Link	Updated
*Medicare*
Medicare Medical	PDF	2/18/26
Medicare Medical Pharmacy	PDF	1/1/26
*Medicaid*
Medicaid Medical	PDF	1/1/26
Medicaid Medical Pharmacy	PDF	1/1/26
*Behavioral Health*
Behavioral Health	PDF	2/18/26
*Dental*
Dental	PDF	1/1/26
Dental Crown Prior Authorization Requirements	PDF	1/1/26

Prior Year's Documents	Updated
Medical Prior Authorization and Notification List	10/1/2025
Behavioral Health Prior Authorization and Notification List	3/5/2025
Direct Access Specialist List	5/6/2022

Medical Authorization and Notification Forms

Medical Authorization Forms

Form Name & Description	Form
Medical Services Request Form Use this form when requesting authorization for medical/surgical services, DME, and out-of-network requests.	4497 (pdf)
Inpatient Authorization Request Use this form when requesting authorization outside of Minnesota, North Dakota, South Dakota, Iowa and Wisconsin.	4494 (pdf)
Medicaid Medical Pharmacy Use this form when requesting authorization for Medicaid Medical Pharmacy. Medicaid Medical Pharmacy generally refers to drugs that are injected or infused by a health care professional in the doctor’s office, infusion center or hospital outpatient. Fax to PerformRx: 866-533-5496.	4493 (pdf)
Medicare Medical Pharmacy Use this form when requesting authorization for Medicare Medical Pharmacy. Medicare Medical Pharmacy generally refers to drugs that are injected or infused by a health care professional in the doctor’s office, infusion center or hospital outpatient.	4493 (pdf)
Early Intensive Developmental and Behavior Intervention (EIDBI) Authorization Used to request authorization for EIDBI services. The form can also be used to request prior authorization for EIDBI services after the threshold has been met.	4894 (pdf)
Private Room Authorization Request Use this form when requesting authorization of a private room in a nursing facility.	4496 (pdf)
Protected Transportation Complete this form for South Country Health Alliance members who have received protected transportation within 72 hours of transport.	6928 (pdf)

Medical Notification Forms

Form Name & Description	Form
Managed Care Referral Request Form ONLY use this form for Restricted Recipient Program (RRP) members. This form is utilized for RRP members which requires a member's primary care provider to submit a referral for all specialists.	>6226 (pdf) >Web Form
Inpatient Admission & Discharge Notification Used when providing notification of an admission or discharge of an acute care hospitalization.	4492 (pdf)
Nursing Facility (NF) Communication Form and Instructions Used for notification of admission to a Nursing Facility.	DHS-4461-ENG (pdf) download only
Critical Access Hospital Swing Bed Notification Form Used for notification of admission to a Swing Bed.	4495 (pdf)
Hospice Notification Form	4735 (pdf)
Recommendation for State Plan Home Care Services (DHS‑5841) Managed Care Organization, County Agency and Tribal Nation Communication Form This PDF may not open in your browser. Instead, download the PDF and open it with Adobe Reader or Acrobat. The downloaded file will be named "form.pdf."	DHS-5841 (pdf) download only

Behavioral Health Authorization and Notification Forms

Behavioral Health Inpatient Admission Form

Form Name & Description	Form
Behavioral Health Hospitalization Inpatient Admission & Discharge Notification Providers within the 5-state area (MN, ND, SD, WI, IA) use this notification form for a behavioral health admission and discharge from a psychiatric facility or mental/behavioral health unit.	5116 (pdf)

Behavioral Health Notification Forms: IRTS, CMIRTS, PRTF, or Partial Hosp

Form Name & Description	Form
Initial Behavioral Health Notification Used to provide notification of IRTS, CMIRTS, PRTF, or Partial Hospitalization services.	4398 (pdf)

Behavioral Health Authorization Forms

Form Name & Description	Form
Behavioral Health Authorization Form Used when requesting prior authorization for Adult Day Treatment, ARMHS (after threshold is met), Certified Peer Specialist (after threshold is met), Adult Crisis Response Services–Residential Crisis Stabilization, Intensive Outpatient Mental Health Treatment (after threshold is met), Partial Hospitalization (after threshold is met), and Psychotherapy (after threshold is met).	4381 (doc)
CTSS
Children's Therapeutic Services and Supports (CTSS) Authorization Form Used when requesting prior authorization for a CTSS services (crisis assistance, family therapy, group therapy, multi-family group, therapy) after threshold is met.	4390 (doc)
EIDBI
Early Intensive Developmental and Behavior Intervention (EIDBI) Authorization Form Used to request authorization for EIDBI services. The form can also be used to request prior authorization for EIDBI services after the threshold has been met.	4894 (pdf)
DBT
Dialectic Behavior Therapy (DBT) Form Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy.	4498 (pdf)

Behavioral Health Home Notification Form

Form Name & Description	Form
Notification of Eligibility for Behavioral Health Home (BHH) Services Fax BHH Notification of Eligibility Form to (507)- 431-6329 See also: Behavioral Health Home and Managed Care Roles and Responsibilities	DHS-4797-ENG (pdf)
Behavioral Health Home and Managed Care Roles and Responsibilities	6715 (pdf)

SUD Notification and Authorization Forms

Form Name & Description	Form
SUD Residential Admission & Discharge Notification Used for inpatient substance use disorder treatment within the surrounding 5 state area (MN, IA, WI, ND, SD).	4505 (pdf)
Out of Network SUD Authorization Used for outpatient (H2035) substance use disorder treatment for providers that are outside of the state of Minnesota. Also used for inpatient (H2036) substance use disorder treatment providers outside the 5 state area (MN, IA, WI, ND, SD).	5991 (pdf)

Healthy Pathways

Healthy Pathways is a program to assist members in preventing mental health deterioration through early intervention and education. This program can also be used as a transition service for those requiring a maintenance level of service or for members who qualify for MH-TCM but opt to use an alternative service instead. Please utilize the following forms to request this service.

Request Form and More Information

Form Name & Description	Form
Healthy Pathways Request Form To be submitted by eligible case manager to initiate, change, renew, or end the service	NEW Online Form (for services starting 3/1/25 or after)
Healthy Pathways Program Overview A detailed description of the Healthy Pathways program including eligibility, services, roles and outcomes for the program.	7504 (pdf)
South Country Individual Treatment Plan Required for Tier 4 requests or for members who have been on Healthy Pathways for 6 months and also work with a care coordinator.	7643 (doc)

Resources

Submitting a Prior Authorization Request

Request authorization by fax

Please use the fax option for services that cannot be requested via the portal. The fax number and contact information will be available on the request forms.

Authorization and Notification Forms

Request authorization online

The preferred method for submitting a prior authorization request is through South Country’s Provider Portal. Most services can be requested through the portal, EXCEPT medical pharmacy requests and certain behavioral health requests. The Provider Portal is a great tool to submit authorization requests, review request status, check claim status and eligibility for your patients.

South Country Health Alliance Provider Portal

Questions?

Providers call 888-633-4055

Members call 866-567-7242

Last Updated on 02/23/2026 by Chris Gartner