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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.



Upon completion, forms listed in this section 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.

SBAR Process

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.


Decision Tree Form


Medical Code TAG (MCT) Decision Tree Form

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 SBAR coding recommendation requests.

The MCT Decision Tree form is being made available for persons submitting SBARs with coding issues and the AUC Medical Code TAG highly recommends its use prior to completing the SBAR. Completion of this form is optional.


Gide Work Request


Guide Work Request Form

Use this form to suggest changes to uniform companion guides.


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