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Frequently asked questions for Hennepin Health SNBC plan members who joined April 1, 2025.

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Forms / formulary

Formulary

  • List of covered drugs (Formulary)
  • List of covered drugs for SNBC members with Medicare coverage (Formulary)

Forms/Info

  • Advance recipient notice of non-covered service/item (PDF)
  • Care management referral  
  • HCBS waiver / AC and ECS case management transfer (PDF)
  • Restricted Recipient Program

The Hennepin County Family Home Visiting (FHV) program offers families home-based services, including prenatal and postpartum care from professionals, parenting support, childhood developmental support and connections to various appropriate resources.  Complete the family home visiting referral form to participate directly or to refer a third party.


Behavioral Health

  • Mental health TCM notification
    Download

Claims and payment

  • Automated clearinghouse ACH funds transfer request
    Download
  • Claims adjustment reconsideration request
    Download
  • Client placement authorization (PDF)
    Download
  • Non-Network Provider Information Form
    Download
  • W9 for contracted providers
    Download
  • W-9 for non-contracted providers (PDF)
    Download

Contracting and credentialing

  • Contract request (PDF)
    Download
  • Disclosure of ownership changes form
    Download
  • Facility credentialing application
    Download
  • Health services checklist (PDF)
    Download
  • Location add/term/change
    Download
  • Location and practitioner roster
    Download
  • Network provider information (PDF)
    Download
  • Practitioner initial credentialing application (PDF)
    Download
  • Practitioner re-credentialing application (PDF)
    Download
  • Practitioner add/term/change
    Download
  • Quarterly complaint
    Download

Pharmacy

  • Prescription drug reconsideration request
    Download
  • Prescription drug prior authorization form (PDF)
    Download

Service authorizations

  • Behavioral health home (BHH) notification (PDF)
    Download
  • Clinical trial attestation (PDF)
    Download
  • Continuity of care
    Download
  • Inpatient admission notification
    Download
  • IRTS extension (more than 90 days)
    Download
  • IRTS initial admission notification
    Download
  • MN Restricted Recipient Program (MRRP) medical referral
    Download
  • Nursing facility communication (DHS form)
    Download
  • Partnered provider out-of-network referral
    Download
  • Service authorization request
    Download
  • Substitute health service request
    Download

Electronic transaction guidelines

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