Administrative Simplification Requirements & Compliance

MS §62J.536 requires group purchasers (payers) and health care providers to use electronic eligibility, claims, payment/advice, and acknowledgment transactions with a single, uniform companion guide to the implementation guides described under Code of Federal Regulations, title 45, part 162. The rules for single, uniform companion guides are known as Minnesota Uniform Companion Guides (MUCGs).

Interested parties may provide input about the rule making process pursuant to MS §62J.61 for MUCGs by submitting comments to health.asaguides@state.mn.us.

MS §62J.536 and related rules require the development and use of MUCGs as companions to HIPAA Implementation Guides. The law, including compliance with the MUCGs, applies to health care providers that provide services for a fee in Minnesota, or who are otherwise eligible for reimbursement under the state's Medical Assistance program, as well as group purchasers and health care clearinghouses that are licensed or doing business in Minnesota.

Minnesota Administrative Simplification Best Practices are consensus recommendations of the AUC to standardize and harmonize health care administrative transactions. The best practices supplement the MUCGs. Adoption or adherence to the best practices is voluntary, but is strongly encouraged to further reduce health care administrative burdens and costs.

MUCGs

MS §62J.497 requires prescription drug prior authorization requests must be accessible and submitted by health care providers, and accepted by group purchasers, electronically through secure electronic transmissions, based on the Minnesota Companion Guide Version 1.1 for the Implementation of NCPDP Electronic Prior Authorization (ePA) transactions [NCPDP SCRIPT Standard version 2013101] (PDF).

MS §62J.497 requires that health care providers requesting exceptions from group purchaser formularies must use the Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions (PDF) as instructed on the form.

MDH ensures compliance with MS §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.

MDH’s approach to enforcement and meeting the goals for standard, electronic transactions will be consistent with the 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.

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.

• Implementation and Compliance Update #1 (PDF)
  Minnesota's Regulations for the Standard, Electronic Exchange of Health Care Administrative Transactions
• Implementation and Compliance Update #2 (PDF);  Cover Memo (PDF)
  Payers (or Their Agents) May Not Charge for Receiving a Standard Transaction
• Implementation and Compliance Update #3 (PDF)
  Standard, Electronic X12 835 Remittance Advices (RAs)
• Implementation and Compliance Update #4 (PDF)
  Limited Exception for Payers Not Subject to HIPAA from Minnesota's Requirements for Only the Standard, Electronic Exchange of Eligibility Transactions (270-271)
• Implementation and Compliance Update #5 (PDF)
  Requirements for Health Care Clearinghouses
• Implementation and Compliance Update #6 (PDF)
  Updated Minnesota Health Care Administrative Simplification Requirements
• Implementation and Compliance Update #7 (PDF)
  Information for Clearinghouses and Others
• Implementation and Compliance Update #8 (PDF)
  Electronic Funds Transfer (EFT) Encouraged for Health Care Claims
• Implementation and Compliance Update #9 (PDF)
  Use ICD-10 for Health Care Dates of Service

A standard complaint form (PDF) and has been developed for submitting complaints of noncompliance with MS §62J.536. Please contact health.asaguides@state.mn.us with any questions and for additional information prior to submitting the form.