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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 (DOC 92KB/2pgs)

Instructions (PDF: 23KB/1pgs)

AUC Payer Contact Information (PDF: 81KB/3pgs) for faxing claims attachments


Appeal Request Form



Claims Appeal Request Form (DOC: 42KB/1pgs)

Instructions (PDF: 25KB/1pgs)

AUC Payer Contact Information (PDF: 81KB/3pgs) 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 (PDF: 252KB/3pgs)

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.



UFEF / minnesota's universal outpatient mental health/chemical health authorization form

Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form (PDF: 139KB/3pgs)


Upon completion, forms listed in this section should be sent to Health.AUC@state.mn.us


Decision Tree Form


Medical Code TAG (MCT) Decision Tree Form (DOC: 150KB/6pgs)

The MCT Decision Tree form is a dual-purpose tool to be completed by the MCT and individuals submitting requests to the AUC for consideration of coding issues related to administrative simplification.

This form is a tool used by the Medical Code TAG as part of its decision-making process regarding medical coding issues and for responding to AUC SBAR coding recommendation requests.

It is also a tool to ensure all information germane for consideration of your coding issue(s) is appropriately documented for the MCT review and to assist you in completing the SBAR.

When completed properly, the MCT Decision Tree expedites a thorough review of your SBAR and response from the AUC.


SBAR


SBAR Form (DOC: 53KB/4pgs)

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

SBAR Process (DOC: 72KB/2pgs)

The purpose of the SBAR form is to provide a formal communication method by which member organizations or non-member interested parties may request the AUC to consider working on administrative simplification issues. This document provides an overview of the SBAR process.


Gide Work Request


Guide Work Request Form (DOC: 82KB/3pgs)

Use this form to suggest changes to uniform companion guides.


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