Provider Quick Reference Guide
| CountyCare Website Visit for documents, forms, important health plan information, and provider and member resources. | www.countycare.com |
| Provider Portal Provides access to member eligibility, important documents, forms, authorization submission and status, claim status, claim review requests, and panel rosters. | Provider Portal Login |
| HFS MEDI System Utilize system to verify Medicaid eligibility. | HFS MEDI Home |
| Universal Provider Roster Submit any provider addition, change or terminations monthly and send a complete IAMHP universal roster quarterly. | [email protected] |
| Member & Provider Services M- F: 8:00AM – 6:00PM CT | 312-864-8200, 711 (TTY/TDD) |
| Transportation Scheduling Contact First Transit to request a ride 3 business days prior to member need. | 630-403-3210 630-873-1440 fax |
| Fraud, Waste and Abuse Hotline Use our confidential hotline to report concerns. | 844-509-4669 |
| Provider Disputes Submit disputes within 60 calendar days from EOP. | www.countycareproviderdispute.jira.evolenthealth.com |
| Critical Incidents Complete a critical incident form. | 312-864-8200, 711 (TTY/TDD) [email protected] |
| Clearinghouse Vendor Availity | availity.com |
| Paper Claims Mailing Address
| CountyCare Health Plan P.O. Box 211592 Eagan, MN 55121-2892 |
| Payer ID | 06541 |
| Claims Timely Filing Requirement
| Submit claims 180 calendar days from date of service or discharge date. |
| Claim Review Process Complete a claim review form within 60 days of EOP receipt. | www.countycare.valence.care 312-864-8200, 711 (TTY/TDD) |
| Inpatient Admissions Contact Member Services within 24 hours of patient admission. | 312-864-8200, 711 (TTY/TDD) 866-209-3703 fax |
| Prior Authorization Look- up Tool Use the look-up tool to determine if an authorization is required. | Prior Authorization Look-up Tool |
| Prior Authorization Requests Medical and Behavioral Health Complete inpatient or outpatient authorization request form. | www.countycare.valence.care |
| Care Management Referrals for Members in HCBS Waivers | 312-864-8200, 711 (TTY/TDD) |
| Referrals to Care Coordination Complete the care coordination referral form. | [email protected] |
| Dental Preauthorization Request at Avesis.com Provider Portal. | Avesis Portal 855-337-1594 |
| Vision Preauthorization Request at Avesis.com Provider Portal. | Avesis Portal 855-337-1596 |
| Pharmacy Preauthorization (including Specialty) Submit the CVS Caremark medication request form. | 800-788-2949 858-790-7100 fax |
| Medical Necessity Appeals Submit appeals within 30 days of an authorization denial. | www.countycare.valence.care CountyCare Health Plan |