Frequently Asked Questions (FAQs)
Minnesota Statutes, section 62J.536 and related rules for the standard, electronic exchange of health care administrative transactions

The following FAQs are provided for information and clarification. They will be revised and updated as needed. Additional information regarding Minnesota Statutes, section 62J.536 and related rules is available at on the Minnesota Department of Health Administrative Simplification Act website at www.health.state.mn.us/asa/index.html.

Last revised: 1/30/2012

FAQ categories

I. More on the Law and Rules: What the Law does, Why it was passed, Who it applies to, etc.

II. Federal HIPAA transactions and operating rules

III. Minnesota Administrative Uniformity Committee (AUC)

IV. Compliance and enforcement by the Minnesota Department of Health (MDH)

V. Implementation, becoming compliant with the state law and rules

VI. Transaction-specific questions: Eligibility inquiry and response, claims, payment and remittance advice, and acknowledgments

 

----------------------------------------------------------------------------------------------


I. More on the state law and rules: What the law does, why it was passed, who it applies to, etc.


1) What does the law do?

The law (i.e., Minnesota Statutes, section 62J.536) simplifies, standardizes, and automates four types of common health care administrative transactions:

  • Checking patient eligibility and reporting back eligibility status;
  • Submitting and adjudicating claims;
  • Producing and receiving a remittance advice; and
  • Sending acknowledgments.

These transactions must be transmitted electronically among providers, payers, and clearinghouses using a single, uniform, standard data content and format.

The law requires the Minnesota Department of Health (MDH) to develop rules for the standard data content and format of the transactions. MDH must consult on the rules with a large, voluntary stakeholder group, the Minnesota Administrative Uniformity Committee (AUC). The rules are to be based on federal HIPAA transactions and code sets regulations and Medicare, although exceptions from Medicare standards are permitted in developing the rules. MDH administers the law and the related rules, including compliance and enforcement. The original law was enacted in 2007 and the initial rules went into effect in 2009. For more information on the history and timeline of the Minnesota Health Care Administrative Simplification Act, visit: www.health.state.mn.us/asa/about.html.


2) Why was this law enacted?

Paper and nonstandard electronic health care administrative transactions are expensive and inefficient for providers, payers, consumers, and government alike. This law is intended to improve efficiency and applies to all providers, payers, and clearinghouses to get the most benefit from electronic, standard exchanges. Electronic data interchange (EDI) can also speed up reimbursement time and enhance the accuracy of a claim before it is submitted for adjudication.

3) What version of the rules is currently in effect and where may I access them?

Minnesota uniform companion guide rules for the following ANSI ASC X12 v5010 and NCPDP D.Ø health care administrative transactions have the force of law as of January 1, 2012:

  • Eligibility inquiries and responses (ANSI ASC X12 270/271)
  • Health care claims (ANSI ASC X12 837I, 837P, 837D, and NCPDP D.Ø)
  • Payment/advice (ANSI ASC X12 835)
  • Acknowledgments (ANSI ASC X12 277CA, 999, TA1)

Copies of the Minnesota uniform companion guides are available at: www.health.state.mn.us/asa. There is no cost for accessing the guides via the website.

4) What are “companion guides”? What is the relationship between the rules and “Minnesota uniform companion guides”? Are the rules the same as the “Minnesota uniform companion guides?

To answer this question, we first provide some background. In 2003, the U.S. federal government implemented regulations under HIPAA for transactions and code sets requirements for the electronic exchange of health care administrative transactions. The regulations require that the transactions be exchanged according to “implementation guides” (IG) that specify the permitted data content and format for the transactions. 

The HIPAA IGs allow individual customization of the data content and format within overall limits. Users of the HIPAA IGs created additional “companion guides” to be used in conjunction with (as “companions” to) the HIPAA IGs, to describe their customization of the IGs. Over time, as payers have implemented their particular customizations of the HIPAA IG data content and format, the number of companion guides has proliferated. This growth of individual companion guides has offset some of the benefits of data standardization that were the basis of the HIPAA IGs.

Minnesota Statutes, section 62J.536, which is part of the Minnesota Administrative Simplification Act, requires MDH to consult with the Minnesota AUC, on the development and adoption of single, uniform companion guides to the HIPAA IGs, rather than allowing administrative transactions to be exchanged according to many different payer-specific companion guides. These “Minnesota uniform companion guides” have been adopted into rule with the force of law as required under Minnesota Statutes § 62J.536. These companion guides comply with the HIPAA IGs and are to be used as the single, uniform companion guides to the HIPAA IGs.

In summary, the Minnesota uniform companion guides are rules with the force of law that:

“…specif[y] the requirements to be used when preparing, submitting, receiving and processing electronic health care administrative data. The document supplements, but does not contradict, disagree, oppose, or otherwise modify the HIPAA Implementation Guide in a manner that will make its implementation by users to be out of compliance. Using this [Minnesota] Companion Guide does not mean that a claim will be paid. It does not imply payment policies of payers or the benefits that have been purchased by the employer or subscriber.”

5) When and how are the Minnesota uniform companion guides/rules updated?

MDH is responsible for routine maintenance and updates of the guides. Requests for changes to the guides may be made by anyone at any time by submitting a Minnesota Uniform Companion Guide Work Request form that can be found at www.health.state.mn.us/auc/aucforms.htm. Requests for changes will be reviewed and compiled for regular annual updates, which currently are scheduled for approximately midyear. Additionally, MDH will respond to other possible needs for updating the guides, arising, for example, from future changes to national standards or HIPAA regulations, or changes in state or federal law. The guides will be updated in consultation with the Minnesota AUC. Proposed updates or changes will be published in the Minnesota State Register, followed by a public comment period, review of public comments, and publication of an announcement of the adopted changes.

6) Who do the law and rules apply to? Who must follow the law? How do I know if Minnesota’s requirements for standard, electronic health care business transactions apply to me/my organization?

The law applies to all:

  • Health care providers who provide services for a fee in Minnesota;
  • Group purchasers (insurance companies, health plans, and other payers) licensed or doing business in Minnesota; and
  • Health care clearinghouses providing services on behalf of covered providers and group purchasers.

6a) What is the definition of “health care provider” that is referenced in statute?

Minnesota Statutes, section 62J.03 subd. 8 defines a health care provider as, “a person or organization… that provides health care or medical care services within Minnesota for a fee and is eligible for reimbursement under the medical assistance program.” (“Eligible for reimbursement under the Minnesota Medical Assistance program” means that the provider’s services would be reimbursed by the Minnesota Medical Assistance program if the services were provided to Medical Assistance enrollees and the provider sought reimbursement.) Pursuant to Minnesota Statutes, 62J.536, subd. 3, providers also include licensed nursing homes, boarding homes, and home care providers.

The definition of “health care provider” includes:

Ambulatory surgical center (ASC)
Audiologist
Certified mental health rehab professional
Certified nurse midwife (CNM)
Certified registered nurse anesthetist (CRNA)
Child and teen checkups (C&TC) clinic
Children’s residential treatment
Chiropractor
Clinical nurse specialist
Community health clinic
Community health clinic
Community mental health center
County case manager
County human services agency
County-contracted mental health rehabilitation
Day training & habilitation (DT&H)/day activity center
Dental hygienist
Dental lab
Dentist/dental group
Family planning agency
Federally qualified health center (FQHC)
Head start agency
Health care case coordinator
Hearing aid dispenser
Home health agency
Hospice
Hospital
Independent diagnostic testing facility
Independent laboratory
Indian health services (HIS) facility
Institution for mental disease (IMD)
Intermediate care facility for the developmentally disabled (ICF/DD)
Licensed independent clinical social worker (LICSW)
Licensed marriage & family therapist (LMFT)
Licensed nutritionist
Licensed professional clinical counselor (LPCC)
Licensed psychological practitioners (LPP)
Licensed psychologist
Licensed registered dietician
Long term care facility (nursing home)
Medical supply/Durable medical equipment
Medical transportation
Mental health targeted case management for SPMI/SED
Nurse practitioner (NP)
Occupational therapist (OT)
Optical company
Optometrist
Personal care assistant (PCA), individual
Personal care provider organization (PCPO)/PCA choice
Pharmacist/Pharmacy
Physical therapist (PT)
Physician/Clinic
Physician assistant
Podiatrist
Private duty nurse (PDN)/Private duty nursing agency
Psychiatrist
Psychologist
Public health clinic
Public health nursing organization
Regional treatment center (RTC)
Registered nurse (RN)/Licensed practical nurse (LPN)
Rehabilitation agency
Renal dialysis
Rural health clinic (RHC)
Speech-language pathologist
Waiver (home & community-based) service provider
X-ray services provider

Note: Providers that are not eligible to obtain a National Provider Identifier (NPI) from the Centers for Medicare & Medicaid Services (CMS) are defined as “atypical” providers in the Minnesota Uniform Companion Guides for Implementation of the Health Care Claim: Professional, Institutional, and Dental (837). The administrative simplification rules apply to these atypical providers.

6b) What is the definition of “group purchaser” that is referenced in statute?  Does it apply to workers’ compensation, property and casualty, and auto insurance carriers?

Minnesota Statutes, section 62J.03 defines “group purchaser” as, “a person or organization that purchases health care services on behalf of an identified group of persons, regardless of whether the cost of coverage or services is paid for by the purchaser or by the persons receiving coverage or services.” The definition of group purchaser applies to individual as well as group coverage, and for both “open” and “closed” books of business. The definition applies regardless of whether or not the entity is actively marketing or servicing policies in Minnesota.

This means that
  • If your organization is licensed or doing business in Minnesota as an insurer, third party administrator (TPA), or other health care payer
And
  • Your organization (or someone on your behalf) is paying—or could potentially have to pay—for medical, dental, or pharmacy claims from a doctor, hospital, or other health care provider who is billing you for services they provided in Minnesota for a fee
Then
  • the law applies to you.

The definition of “group purchaser” includes:

  • Group health insurance carriers;
  • Property-casualty insurance carriers;
  • Workers’ compensation carriers;
  • Auto carriers;
  • TPAs;
  • The Minnesota Department of Human Services, which administers Medical Assistance, MinnesotaCare, and other programs; and
  • Other payers.

6c) What is the definition of “health care clearinghouse” that is referenced in statute?

Minnesota Statutes, section 62J.51, subd. 11a defines a “health care clearinghouse” as, “a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and ‘value-added’ networks and switches.” Software vendors are also considered to be “health care clearinghouses.” A health care clearinghouse performs any of the following functions:

  • Processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction;
  • Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity;
  • Acts on behalf of a group purchaser in sending and receiving standard transactions to assist the group purchaser in fulfilling its responsibilities under section 62J.536;
  • Acts on behalf of a health care provider in sending and receiving standard transactions to assist the health care provider in fulfilling its responsibilities under section 62J.536; and
  • Other activities including but not limited to training, testing, editing, formatting, or consolidating transactions.

A health care clearinghouse acts as an agent of a health care provider or group purchaser only if it enters into an explicit, mutually agreed upon arrangement or contract with the provider or group purchaser to perform specific clearinghouse functions.

As per section 62J.536, health care clearinghouses must also:

  • Make available tracking mechanisms for providers and payers to determine if health care claims and/or remittance advices were delivered;
  • Connect electronically in a timely manner with any entity willing and capable of meeting the standard business terms and conditions of the clearinghouse and any applicable laws and regulations; and
  • Provide and make available information as required by the Minnesota Commissioner of Health.

MDH published an Implementation and Compliance Update #5 to provide further information.

6d) Do the requirements of Minnesota Statutes, section 62J.536 apply to Medicaid subrogation or other payer to payer exchanges?

No. The requirements for standard, electronic exchanges of health care administrative transactions apply only to HIPAA-covered transactions. HIPAA does not include Medicaid subrogation, and Minnesota’s requirements do not apply to Medicaid subrogation or other payer to payer exchanges.

6e) Do the requirements of Minnesota Statutes, section 62J.536 apply to secondary and tertiary payers, and to coordination of benefits (COB)?

Yes. Minnesota’s rules apply to secondary and tertiary payers other than for claims that are electronically crossed over from Medicare to another Minnesota payer. Instructions on sending prior payer adjudication information on a subsequent claim submission are found in Section 4.2.3 and its corresponding subsections of the Minnesota Uniform Companion Guides for the Health Care Claim: Professional, Institutional, and Dental (837).

Additional information on COB exchanges can be found in the listings of AUC best practices.

6f) What if we are an insurance carrier (i.e. “group purchaser”) in Minnesota, but we no longer write policies here? Do the law and rules still apply?

Yes. The law and rules still apply to “closed” books of business as well as open books of business. Even if you no longer write (or never wrote) policies in Minnesota, if you are licensed or doing in business in Minnesota and if you could be responsible for medical claims incurred by your insured(s) for treatment from a health care provider providing their services for a fee in Minnesota, the law and rules apply.

6g) My organization pays the insurance policy holder directly for care provided. We never pay a health care provider. Does the law apply to us?

No. While we encourage the use of standard, electronic health care transactions as widely as possible, Minnesota’s law and rules apply to covered exchanges between health care providers and group purchasers, and health care clearinghouses acting on their behalf. Claims submitted directly by the insured/patient to a payer are not part of the requirements.

7) Are there any exceptions to the law’s requirements?

Minnesota Statutes, section 62J.536 does not apply to:

  • Transactions with Medicare or Medicare Advantage products; or
  • Claims submitted by a patient/insured directly to the insurer/payer.

Note: The statute allows for only one other very limited, targeted exception for group purchasers not covered by federal HIPAA regulations, where the following criteria are met:

  • A transaction is incapable of exchanging data that are currently being exchanged on paper and is necessary to accomplish the purpose of the transaction; or
  • Another national electronic transaction standard would be more appropriate and effective to accomplish the purpose of the transaction.

These criteria have been met and a targeted, very limited exception from the rules has been granted only from the requirement to electronically exchange eligibility inquiries and responses only to payers not covered by federal HIPAA transactions and code sets regulations (i.e., property and casualty, auto, and workers’ compensation carriers). However these carriers must still comply with the requirements for the standard, electronic exchange of claims and payment remittance advices. This narrow exception if reviewed annually, and the exception is continued only if the criteria above are met. See Implementation and Compliance Update #4.2 for more information.

7a) Can small providers such as those without computers or with few transactions receive an exception or be allowed to delay implementation? Can small payers not covered by federal HIPAA transactions and code sets regulations receive an exemption?

No. The only exceptions to the requirements in Minnesota Statutes, section 62J.536 are those noted in the answer to Question 5 within this section. Minnesota Statutes, section 62J.536 and related rules apply to all health care providers, as well as all group purchasers (payers) as previously described.

The benefits of standardization are greatly reduced or lost when there are exceptions or exemptions. Providers and payers have a number of options to comply with the law and rules that best meet their business needs, including a wide variety of arrangements, clearinghouses, vendors, and service providers. In addition, while there may be start-up and transition costs to become compliant with the law and rules, the standard electronic transactions will also result in quicker payment, and more efficient, less costly transactions over time.

Back to Top

 

II. Federal HIPAA transactions and operating rules


1) What is HIPAA? What do I need to know about HIPAA with respect to administrative simplification?

HIPAA stands for the Health Insurance Portability and Accountability Act. Title II of HIPAA includes a series of health care administrative simplification provisions that call for: the establishment of standards for electronic health care transactions; unique identifiers for employers, health plans, and health care providers; and privacy and security standards to protect health information.

National standards for these areas are established by the Secretary of Health and Human Services through the rulemaking process. Final HIPAA rules have been issued adopting standards and requirements for electronic transactions and code sets, a unique employer identifier, the national provider identifier, and privacy and security of health information. Civil and monetary penalties and federal criminal penalties may be imposed for the violation of HIPAA standards.

HIPAA calls for changes designed to streamline the administration of health care, eliminate proprietary formats and methods to codify and exchange information, and automate administrative processes to improve efficiencies in the health care industry and ultimately the quality of health care services provided.

Entities subject to HIPAA (known as “covered entities”) include: (1) all health plans [i.e. payers, group purchasers, carriers, third party administrators (TPA), etc.]; (2) all health care clearinghouses; and (3) health care providers that choose to conduct administrative transactions electronically.

2) What are HIPAA transactions and code sets regulations? How do they relate to Minnesota’s law and rules?

One group of federal regulations issued by the Secretary of Health and Human Services (HHS) in response to the administrative simplification provisions of HIPAA was the HIPAA Transactions and Code Set Regulations. Transactions are a set of defined activities involving the exchange of health care information (for example, a health care claim). Code sets are standard codified representations of certain health information that are included in a transaction (for example, coding the diagnosis of a patient using the ICD-9 code set). National compliance with the HIPAA Transactions and Code Sets Regulations started October 16, 2003 for all covered entities.

The HIPAA Transactions and Code Sets Regulations establish national standards to be used in the electronic exchange of selected transactions including transaction standards for health care claims or equivalent encounter information, claim payment/advice, claim status inquiry and response, eligibility inquiry and response, coordination of benefits, referral certification and authorization inquiry and response, claim status inquiries and response, enrollment/disenrollment in a health plan, and health plan premium payment. Subsequent amendments to the HIPAA regulations as part of the Patient Protection and Affordable Care Act (PPACA) in 2010 also required adoption of standards for electronic funds transfer (EFT) and claims attachments.

Standard code set names and descriptions

Standard code set name

Description

Code on Dental Procedures and Nomenclature (CDT)

Dental services

Current Procedural Terminology, Fourth Edition (CPT©)

Physician services/other health services

Health Care Financing Administration Common Procedure Coding System (HCPCS)

Physician services/other health services and medical supplies, orthotics, and durable medical equipment (DME)

International Classification of Diseases, 9th Edition, Clinical Modification, Volumes 1 and 2 (ICD-9-CM)*

Diagnoses

International Classification of Diseases, 9th Edition, Clinical Modification, Volume 3 (ICD-9-CM)*

Inpatient hospital procedures

National Drug Codes (NDC)

Drugs/biologics

*Covered entities are to transition from using ICD-9 code sets to using ICD-10 code sets by October 1, 2013.

Relationship to Minnesota’s law and rules: Minnesota Statutes, section 62J.536 requires group purchasers, providers, and clearinghouses to exchange certain health care administrative transactions electronically. These transactions include health care eligibility benefit inquiries and responses, claims, payment/remittance advices, and acknowledgments. Consistent with HIPAA, group purchasers, providers, and clearinghouses are required to use the national standards and implementation guides adopted by the Secretary of Health and Human Services. As previously noted, all users to which the Minnesota rules apply are required to use the Minnesota uniform companion guides.

3) Where can I find the HIPAA Implementation Guides?  Does my organization need to buy them in order to be compliant?

The HIPAA Implementation Guides—the documents used to implement the national electronic standards adopted by HIPAA for the named administrative transactions—can be found at the following locations:

  • The HIPAA Implementation Guides are available for a fee from the Washington Publishing Company at www.wpc-edi.com. These guides are developed by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12 Committee (www.x12.org).
  • Retail pharmacy standard, electronic transactions are available from the National Council for Prescription Drug Programs (NCPDP) at www.ncpdp.org. There is a fee for non-members of NCPDP to obtain a copy of the NCPDP implementation guides for the retail pharmacy transactions.

If you have general questions about the HIPAA Implementation Guides, you can begin with your practice management software vendor, health care clearinghouse, or the EDI contact at your trading partner organizations.

ASC X12 Committee responses for formal interpretations of its implementation guides are available at http://www.x12.org/x12org/subcommittees/x12rfi.cfm. These responses are commonly known as Requests for Interpretation, or “RFIs”.

In most cases, depending on the size of the organization and the volume of transactions being exchanged, the organization will depend on and work with their practice management software vendor or health care clearinghouse to meet the HIPAA Transactions and Code Sets Regulations and may not need to purchase the HIPAA and NCPDP implementation guides.

4) What do I have to know about HIPAA privacy and security rules—do they apply to me?

All health plans and health care clearinghouses are subject to comply with the HIPAA privacy and security rules. Health care providers that conduct any of the HIPAA administrative transactions electronically are also subject to comply with the HIPAA Privacy and Security Rules. HIPAA covered entities are required to apply the same privacy and security requirements they are subject to comply with in agreements with business associates. Refer to the U.S. Department of Health and Human Services website to learn how to comply with the privacy and security rules.


5) What are federal operating rules for HIPAA transaction standards? Where can I find them?

The Patient Protection and Affordable Care Act (PPACA), which was enacted in 2010, includes administrative simplification provisions for HIPAA-covered entities in Section 1104. Specifically, PPACA requires HHS to adopt operating rules for selected HIPAA transactions with the intent to create more uniformity in the implementation of the electronic standards.

According to HHS, operating rules augment the HIPAA transaction standards in three ways:

  • They contain additional requirements that help implement the standard for a transaction in a more consistent manner across health plans;
  • They address ambiguous or conditional requirements in the standard and clarify when to use or not use certain data elements or code values; and
  • They specify how trading partners, including providers, should communicate with each other and exchange patient information, with the goal of eliminating connectivity inconsistencies.

Pursuant to PPACA, HHS is to adopt operating rules for nine electronic transactions, three of which are already mandated in Minnesota and two of which the Minnesota AUC has developed best practices for to standardize their use. The table below shows the covered transactions and the dates by which HHS is to adopt operating rules, their effective dates, and the dates by which health plans are to certify compliance with these rules.

Operating rule adoption, effective, and compliance dates for covered transactions

Transaction operating rules

Adoption

Effective

Compliance

Eligibility *

07/01/11

01/01/14

12/31/13

Claim status

“ “

“ “

“ “

Electronic funds transfer **

07/01/12

“ “

“ “

Payment/advice *

“ “

“ “

“ “

Claims *

07/01/14

01/01/16

12/31/15

Enrollment/disenrollment in a health plan

“ “

“ “

“ “

Health plan premium payments

“ “

“ “

“ “

Claims attachments **

“ “

“ “

“ “

Referral certification/authorization

“ “

“ “

“ “

Source: Publ. L. No. 111-148.

* Minnesota Statutes Section 62J.536 mandated the use of these transactions along with single, uniform companion guides.

** The Minnesota AUC has developed and published best practices to standardize the use of electronic funds transfer and claims attachments (see http://www.health.state.mn.us/auc/bp.htm).


The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) authored the operating rules and they are available for free on its website www.caqh.org/COREv5010.php. HHS adopted operating rules for the eligibility and claim status transactions on June 30, 2011 which have an effective date of January 1, 2014. See CMS-0032-IFC Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions for more information.

6) Do the federal operating rules apply to me? How do they relate to Minnesota’s administrative simplification law and rules?

The operating rules apply to all:

  • Health care providers who provide services for a fee in Minnesota;
  • Group purchasers (insurance companies, health plans, and other payers) licensed or doing business in Minnesota; and
  • Health care clearinghouses providing services on behalf of covered providers and group purchasers.

The Minnesota Department of Health (MDH) and the Minnesota Administrative Uniformity Committee (AUC) are currently reviewing the eligibility operating rules to determine what, if any, changes should be made to the Minnesota Uniform Companion Guide for the Implementation of the Health Care Eligibility Benefit Inquiry and Response (270/271).

Back to Top

 

III. Minnesota Administrative Uniformity Committee (AUC)


1) What is the Minnesota Administrative Uniformity Committee (AUC)?

The Minnesota Department of Health (MDH) is statutorily required to consult with the Minnesota AUC, on rules for the data content and format for standard, electronic health care administrative transactions. The AUC is a broad-based, voluntary organization representing Minnesota’s public and private health care payers, hospitals, health care providers and state agencies. It has served since 1992 to develop agreement among payers and providers on standardized administrative processes. The AUC acts as a consulting body to various public and private entities, but does not formally report to any organization and is not a statutory committee. It meets as a large committee of the whole, as well as through numerous work groups and Technical Advisory Groups (TAG). The work groups and TAGs reflect particular areas of expertise and divisions of labor with respect to different types of health care administrative transactions and processes.

2) How can I find out about the activities and scheduled meetings of the Minnesota AUC?

Information regarding the Minnesota AUC and its activities can be found at the AUC website at www.health.state.mn.us/auc. In particular, the website calendar includes a posting of upcoming AUC meetings and activities, as well as links to meeting agendas, minutes, and other materials. AUC meetings and activities are open to the public.

3) What are the Minnesota AUC’s “best practice” documents? What is the difference between the Minnesota uniform companion guides and the AUC best practice documents?

The Minnesota uniform companion guides are rules for the standard data content and format of standard, electronic health care administrative transactions. They are mandatory and have the force of law. MDH collaborates with the Minnesota AUC in developing the guides.

AUC best practices are consensus recommendations of the AUC to further standardize and harmonize health care administrative transactions. However, best practices are not mandatory and do not have the force of law. While adoption or adherence to the AUC best practices is voluntary, it is strongly encouraged to further reduce health care administrative burdens and costs. The AUC best practices (as well as copies of the rules) can be found at the AUC website, www.health.state.mn.us/auc.

Back to Top

 

IV. Compliance and enforcement by the Minnesota Department of Health (MDH)


1) What does the law say about compliance and enforcement? How will the law be enforced?

The Minnesota Department of Health (MDH) ensures compliance with Minnesota Statutes section 62J.536 and related rules. The statute provides that:

  • MDH is to achieve voluntary compliance to the extent practicable, and may provide technical assistance;
  • Enforcement will be complaint-driven;
  • MDH may investigate complaints, and is to seek informal resolution of complaints, for example through demonstrated compliance or a completed corrective action plan or other agreement;
  • If informal resolution is not possible, MDH may impose civil money penalties of up to $100 for each violation, but not to exceed $25,000 for identical violations during a calendar year;
  • Mitigating factors, such as whether attempts are being made to come into compliance, may be considered in determining any penalties; and,
  • If a fine is levied, it may be appealed or a contested case hearing requested.

Even with the best communication and planning, providers and payers may still encounter possible problems during the initial implementation of version 5010 of the standard, electronic administrative HIPAA transactions.  

MDH is committed to working with the industry to help identify and solve problems as quickly as possible while also achieving the goals of more standard, efficient transactions. As part of this commitment, MDH will use its considerable regulatory flexibility to help minimize the possibility of delays or interruptions in routine administrative transactions during implementation of the rules

MDH’s enforcement goal is to help assure that routine health care business transactions can flow more rapidly and efficiently—not to collect fines for noncompliance. In enforcing the statute and related rules, MDH will be especially interested in:

  • Whether good faith efforts are being made to comply;
  • The extent of compliance efforts; and
  • Progress toward compliance.

In summary, MDH’s approach to enforcement and meeting the goals for standard, electronic transactions will be flexible, practical, and consistent with an overall statutory enforcement policy of:

  • Seeking voluntary compliance and offering technical assistance;
  • Responding to complaints;
  • Working toward informal resolution of complaints; and
  • Considering possible mitigating factors.

Complaint form: MDH strongly encourages all providers and payers to review and consider the information provided here. However, as noted, MDH is charged with investigating any complaints submitted related to Minnesota Statutes, section 62J.536.

The standard complaint form is available online in PDF format, and all potential users are encouraged to also review the MDH Implementation and Compliance Updates prior to submitting complaints.

2) As a group purchaser (payer), am I required to reject noncompliant claims?

Payers and their clearinghouses (or any organization acting on the payer’s behalf) must be able to demonstrate they have the capability to accept Minnesota-compliant, standard, electronic transactions. However, MDH does not require payers to reject noncompliant claims. MDH encourages payers to work with providers to aid them in coming into compliance before taking steps to reject noncompliant claims.

3) Does my organization have to send the Minnesota Department of Health (MDH) information regarding its readiness for compliance?

MDH does not require any particular information from payers, providers, or their clearinghouses regarding their readiness to comply with Minnesota Statutes, section 62J.536.

4) If my trading partners are not in compliance with the law by the implementation dates, what should I do? When should I file a complaint? How do I file a complaint? What happens when a complaint is filed?

It will be important for trading partners to communicate and work together before, during, and after the law’s effective dates to be compliant. Per statute, enforcement of Minnesota’s requirements for standard, electronic health care business transactions is complaint-driven. The statute also states that MDH is to seek informal resolution of complaints, and, if informal resolution is not possible, it may consider a number of mitigating factors before imposing any fines or penalties. During the initial implementation phases of the rules especially, we encourage trading partners to find ways to work together for compliance. 

Parties may also consider filing a complaint of noncompliance with MDH for investigation and possible follow-up. However, it is important to note that the complaint filing and follow-up process is prescribed in statute, and that it requires specific steps in filing the complaint, providing notice to the subject(s) of the complaint, investigation of the complaint, and other steps. While complaints are an important and necessary option in some instances, the complaint process does require time and/or effort that may also be usefully spent in communicating about problems and working toward solutions.

Reading the MDH Implementation and Compliance Updates is strongly encouraged to learn more about MDH’s approach to enforcement of Minnesota Statutes, section 62J.536.

Back to Top

 

V. Implementation, becoming compliant with the state law and rules


1) What are the options for providers to connect electronically with payers?

There are many options for providers to connect electronically with payers, ranging from direct Electronic Data Interchange (EDI) connections, to contracting with a variety of vendors and services (e.g., clearinghouses, billing services, etc.) to secure web-based “direct data entry” tools that allow providers to directly key in and transmit Minnesota-compliant claims to payers. It will be important to evaluate options to find those that best meet your business needs. Many providers are consulting with their associates, payers, business advisors, professional and trade associations, and others for advice and possible recommendations.

2) Does the Minnesota Department of Health (MDH) or anyone have a list of recommended vendors?

MDH does not have a list of recommended vendors. As noted in the answer to Question 1, there are many options for providers to connect with payers electronically, and it is important for providers to find the option that best meets their needs. MDH does not require use of any particular vendor or services and does not endorse or recommend any particular vendors.

3) Will MDH be providing a low cost or free way to connect and send the required electronic transactions?

MDH does not have responsibilities or resources for offering free or low cost electronic connectivity and MDH will not be providing such a service. 

Note: Another state agency, the Minnesota Department of Human Services (DHS), maintains a secure web portal called MN-ITS for providers to submit claims for free for patients who are covered under DHS public programs such as Medical Assistance or MinnesotaCare.

In 2009, the Minnesota Council of Health Plans announced the availability of a direct data entry web portal for providers to submit health care claims to participating group purchasers at no cost to the provider (for additional information about this option, please see: www.mneconnect.com). MDH is not aware whether there may be other web portal options available at a low cost or no cost to providers. Again, as noted previously in these FAQs, MDH does not require or endorse any products or vendors.

4) What information do I need (what questions do I need to ask) to connect electronically? Where can I find information on how to connect?

Providers should contact their payers, or check payers’ websites, for information on how to connect electronically.

Back to Top

 

VI. Transaction-specific questions: Eligibility inquiry and response, claims, payment and remittance advice, and acknowledgments


I am not familiar with the transactions covered by the law. What is an “eligibility inquiry and response”? What is a “health care claim”?  What is a “health care claim payment and remittance advice”? What is an “acknowledgment”?

Minnesota has developed rules for the standard, electronic exchange of four types of health care administrative transactions, as described below:

The health care eligibility benefit inquiry and response transaction is the transmission of either of the following:

  • An inquiry from a health care provider to a group purchaser, or from one group purchaser to another group purchaser, to obtain any of the following information about a benefit plan for an enrollee:

    - Eligibility to receive health care under the group purchaser;
    - Coverage of health care under the group purchaser; and/or
    - Benefits associated with the group purchaser.

  • A response from a group purchaser to a health care provider's (or another group purchaser's) inquiry described in paragraph (a) of this section.
The health care claims or equivalent encounter information transaction is the transmission of either of the following:
  • A request to obtain payment, and the necessary accompanying information from a health care provider to a group purchaser, for health care; or
  • If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.
The health care claim payment/remittance advice transaction is the transmission of the following from a group purchaser to a health care provider: explanation of benefits; and remittance advice.

The health care claim acknowledgment transactions are used to: report syntax errors; report HIPAA TR3 errors; acknowledge receipt; and accept or reject. Acknowledgment transactions include:
  • Delivery or interchange (TA1);
  • Syntax and HIPAA TR3 response, or implementation (999); and
  • Business application or claims (277CA).

ELIGIBILITY INQUIRY AND RESPONSE

1) We know that as of January 15, 2009, when we check a patient's eligibility for insurance coverage and benefits, it has to be done electronically. What does "electronically" mean for us? Can eligibility and benefits ever be verified by calling and talking to a live person, or by calling and using an automated Interactive Voice Response (IVR) telephone system?

"Electronically" means that initial eligibility inquiries and responses must exchanged either via compliant internet ("web") or "electronic data interchange" (EDI) connections. Interactive Voice Response (IVR) is not compliant for this initial exchange. If, after an initial compliant exchange (via web or EDI) additional information or review is needed, other options that may be available from payers may be used, including IVR. Many in the industry are transitioning away from the IVR systems they had made available to check eligibility and are putting into place compliant web-based and EDI alternatives. We appreciate and encourage everyone's good faith efforts in making this transition.

2) Does version 5010 of the eligibility transaction offer any more functionality than the previous 4010 version? For example, as a provider, will I receive information on patient responsibility?

Yes, the 5010 eligibility transaction has been enhanced. With 5010, the payer is required to report the following data in its response to an eligibility request from a provider:
  • A monetary amount or percentage amount the patient is responsible to pay, when reporting co-insurance, co-payment, deductible, and similar information;
  • How the patient is to be identified on subsequent transactions, such as the claim;
  • The health plan name, effective dates of the health plan, and any required demographic information; and
  • Benefit information for medical care, chiropractic care, dental care, hospital, emergency services, pharmacy, professional visit—office, vision, mental health, and urgent care.

Moreover, in developing the version 5010 Minnesota Uniform Companion Guide for the Implementation of the Health Care Eligibility Benefit Inquiry and Response (270/271), the Minnesota AUC determined that payers would return additional benefit information—such as patient out-of-pocket costs and the remaining deductible—to help providers that see patients who are on high-deductible and high co-insurance health plans.

3) Has the Minnesota AUC developed any eligibility best practices?

Yes, the Minnesota AUC has developed several eligibility best practices that can be found at www.health.state.mn.us/auc/bp.htm.


CLAIMS

1) Each of the Minnesota uniform companion guides includes “Required,” “Situational,” or “Not Considered for Processing” in the “Usage” column. Do the required fields/elements have to be used in processing?

ALL of the segments/fields/elements that are classified as REQUIRED in the HIPAA Implementation Guides and the NCPDP Guides must be sent by the submitter. In some instances that are identified in the Minnesota Uniform Companion Guides for Implementation of the Health Care Claim: Professional, Institutional, and Dental (837), the receiver may choose to not use the submitted element when processing the transaction.

2) We often deny claims for multiple reasons. What is the Minnesota requirement for denied claims [i.e., is a claim payment/advice (835) transaction required]?

Claims transactions that have passed basic edits which have not been rejected due to general envelope, formatting or transaction validation issues, and for which claim processing has been initiated in the payer’s system, require a Health Care Claim Payment/Advice (835) transaction. The 835 transaction must document the claim adjustments via Claim Adjustment Reason Codes (CARC), claim adjustment group codes, and Remittance Advice Remark Codes (RARC), including claim denials, as outlined for use in Table B.1 in the Minnesota Uniform Companion Guide for the Implementation of the Health Care Payment/Advice (835).

3) Can we reject the transaction if the claim number is not entered?

There are several claim numbers in the transaction. All are situational.

  • The Original Reference Number (ICN/DCN) is situational, and only required when claim submission reason codes are 6 (Corrected claim), 7 (Replacement claim) or 8 (Void) and the payer has assigned a number to the original claim.
  • The Property and Casualty (P&C) Claim Number is situational and should be reported when known. You should not deny the bill simply because it is missing this number but you could deny it if you are unable to match the bill to a P&C claim. (The claim number field is situational but is required if the claim is a P&C or Workers’ Compensation claim. As such, if a clearinghouse knows that the destination group purchaser is a P&C-only carrier, they can edit it at the clearinghouse and deny it back to the provider to obtain the P&C claim number.)
  • The Repriced Claim Number is situational.

4) What are Minnesota community coding practices and recommendations?

The Minnesota AUC Medical Code TAG develops coding recommendations. Those that have been approved by the Minnesota AUC are included in the “Minnesota Community Coding Practice/Recommendation Table”. The table:

  • Provides clarification and answers to frequently asked questions about recommended ways to code for health and medical services on the 837I and 837P electronic claim;
  • Is intended for use in conjunction with “Appendix A, Table A.5.1” of the “Minnesota Uniform Companion Guides for the 837 Institutional (I) and 837 Professional (P) transactions;
  • Is regularly updated; and
  • Is informational only – It is not part of the Minnesota uniform companion guides and does not serve as a rule.

5) How do I send claims attachments in accordance with the law?

Claims attachments are addressed in all Minnesota Uniform Companion Guides for Implementation of the Health Care Claim: Professional, Institutional, and Dental (837) in section 4.2.3.

A supplemental AUC best practice for the submission of claims attachments and the claims attachment cover sheet can be found on the Minnesota AUC website.

If you have additional questions about sending claims attachments, the Minnesota Department of Health (MDH) suggests you contact your clearinghouse or the appropriate payer. Do not send claims attachments to MDH.

6) How do I request a claims adjustment or appeal in accordance with the law?

Claims adjustments and appeals are addressed in all Minnesota Uniform Companion Guides for Implementation of the Health Care Claim: Professional, Institutional, and Dental (837) in section 4.2.3.

A supplemental AUC best practice for requesting a claims appeal and the appeal request form can be found on the Minnesota AUC website.

If you have additional questions about requesting a claims adjustment or appeal, MDH suggests you contact your clearinghouse or the appropriate payer. Do not send appeal request forms to MDH.

7) How do I replace and void claims in accordance with the law?

Claims replacements and voids are addressed in all Minnesota Uniform Companion Guides for Implementation of the Health Care Claim: Professional, Institutional, and Dental (837) in section 4.2.3.

A supplemental AUC best practice for claims replacements and voids can be found on the Minnesota AUC website.

If you have additional questions about replacing or voiding claims, MDH suggests you contact your clearinghouse or the appropriate payer.

8) Does the Minnesota uniform companion guide address how to bill for MinnesotaCare (MNCare) Tax on a claim?

Yes. The Minnesota Uniform Companion Guides for Implementation of the Health Care Claim: Professional, Institutional, and Dental (837) offer guidance on this topic in each guide’s respective appendix section.


CLAIM PAYMENT/ ADVICE

Does the Claim Payment/Advice component of the law require that payments be sent electronically? Does my organization need to send “electronic funds transfer” (EFT) payments to health care providers as well?

MDH encourages electronic payment (i.e., electronic funds transfer, or EFT) as a further means of reducing health care administrative costs and burdens. However, Minnesota Statutes, section 62J.536 does not require electronic payment. Group purchasers and providers may be subject to other requirements or trading partner agreements which require the transmission of an electronic payment. It is recommended that each organization familiarize itself with its payment procedures as it may relate to the claim payment/advice transaction.

The Minnesota AUC developed and published an Electronic Funds Transfer (EFT) (PDF: 57KB/1pgs) best practice that outlines standard EFT processes for providers, group purchasers, and financial institutions.


ACKNOWLEDGMENTS

Has the Minnesota AUC developed any acknowledgments best practices?

Currently, the Minnesota AUC is developing acknowledgments best practices, but they are preliminary and have not yet been published.

Back to Top


Link to Adobe Acrobat Reader To view the PDF files, you will need Adobe Acrobat Reader (free download from Adobe's website).

Updated Wednesday, 05-Feb-2014 15:15:59 CST