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Minnesota AUC Administrative Simplification
 

Forms

The three forms below should be sent to the appropriate payer
(Not to the MN Department of Health or the AUC)


Attachment Cover Sheet

 

Claims Attachment Cover Sheet

Instructions (pdf: 1 page)

AUC payer contact information for faxing claims attachments


Appeal Request Form


Claims Appeal Request Form

Instructions (pdf: 1 page)

AUC payer contact information for faxing appeals forms

This Form is to be used when a provider is requesting a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted.


UFEF / prescription drug PA request form

 

UFEF / prescription drug PA request form

The form is intended primarily for use by prescribers, or those designated and authorized to act on behalf of prescribers, to:
1. Request an exception to a prescription drug formulary.
2. Request a prior authorization (PA) for a prescription drug.



The two forms below should be sent to Health.AUC@state.mn.us


SBAR


SBAR Form

Use this form in accordance with Policy #10 (pdf: 2 pages) to request that the AUC conduct work on a particular administrative simplification issue.


Gide Work Request


Guide Work Request Form

Use this form to suggest changes to uniform companion guides.


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