New Facility Claim Requirements

Required Forms

If you are a new provider to IMCare and need to submit a claim or payment request for health care services or supplies, you must submit the following forms for provider set-up before we can process your claims:

Please return all forms completed in entirety and in accordance with the instructions, even if you are exempt from backup withholding. The forms must be completed in a legible manner and should contain accurate and current information. Except for the EFT/ERA Authorization Agreements which must be mailed, you can fax completed forms to 218-327-5545 or mail them to:
IMCare Claims Department
1219 SE 2nd Avenue
Grand Rapids, MN  55744


IMCare requires all facilities to register prior to submitting claims. As part of the registration process, please complete the Non-Contracted Facility Information Form (PDF). This form will enable IMCare to add your facility to our claims processing system in a timely and accurate manner. Please include all requested information. IMCare will not accept claims electronically prior to receiving this information from your facility.

Non-Contracted Facilities

We also need to collect information on practitioners providing services at non-contracted facilities. Please complete the Practitioner NPI/UMPI Notification/Request Form (PDF) for all practitioners providing services billable to IMCare. The information will be added to our claims processing system to process submitted claims. The Practitioner NPI/UMPI Notification/Request Form (PDF) requires inclusion of a Social Security Number (SSN). This will be shared with the State of Minnesota for reporting purposes only.

W-9 Tax Form

In compliance with Internal Revenue Services (IRS) regulations, IMCare requests that you also provide a completed W-9 Form (PDF). Please pay particular attention to the following for the W-9 Form (PDF):
  • Individual Taxpayer Identification Number (TIN):
    • When including a Social Security Number (SSN): Only the name of the person whose SSN is included should be entered on the first line. Include the last name, first name, and middle initial.
    • When including an Employer Identification Number (EIN): The name of the partnership, corporation, sole proprietorship, club, or other entity must be entered on the first line exactly as it was registered with the IRS when the Federal EIN was assigned.
Please do not submit a TIN that has not been assigned to your name. For example, a health care provider who submits his/her name on a W-9 must have his/her own SSN. If a health care provider uses the clinic name, then the W-9 must contain the Federal EIN of the clinic.

Only one TIN can be submitted on the form. Do not list both an SSN and an EIN.

Electronic Remittance Advices

Electronic Remittance Advices (ERA) was mandated by Minnesota Statute 62J.536, which requires all providers in the State of Minnesota to receive explanations of payment (EOPs) electronically after December 15, 2009.

The ERA is a time saver both in terms of posting payments and accuracy. IMCare requires all Minnesota providers to register to receive their ERA 835 remittances through their clearinghouse. ERA options require the provider to complete the EFT/ERA Authorization Agreement. Please see the Electronic Remittance Advices (ERA) 845 page for more information about signing up for our web portal.

Rejected Claims

As a Managed Care Organization (MCO) contracted with the Minnesota Department of Human Services (DHS) to administer health care benefits, we are required to submit certain provider information to the State. Failure to provide a W-9 Form (PDF), the Non-Contracted Facility Information Form (PDF), and the Practitioner NPI/UMPI Notification/Request Form (PDF) (if applicable) will result in the denial/rejection of your claims.

If you receive a claim denial or rejection and you then submit the required information, you must also submit your denied/rejected claim. Please allow 15 business days between submitting the required information and resubmitting your claim.