Frequently Asked Questions (FAQs)
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.
Last revised: 1/30/2012
Category 1 - More on the state law and rules: What the law does, why it was passed, who it applies to, etc.
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 the Health Care Administrative Simplification Act (ASA) webpage
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.
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 on the Minnesota Uniform Companion Guides webpage. There is no cost for accessing the guides via the website.
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.”
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 on the AUC Forms webpage. 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.
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)
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
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
Family planning agency
Federally qualified health center(FQHC)
Head start agency
Health care case coordinator
Hearing aid dispenser
Home health agency
Independent diagnostic testing facility
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 professional clinical counselor (LPCC)
Licensed psychological practitioners (LPP)
Licensed registered dietician
Long term care facility (nursing home)
Medical supply/Durable medical equipment
Mental health targeted case management for SPMI/SED
Nurse practitioner (NP)
Occupational therapist (OT)
Personal care assistant (PCA), individual
Personal care provider organization (PCPO)/PCA choice
Physical therapist (PT)
Private duty nurse (PDN)/Private duty nursing agency
Public health clinic
Public health nursing organization
Regional treatment center (RTC)
Registered nurse (RN)/Licensed practical nurse (LPN)
Rural health clinic (RHC)
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
- 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
- the law applies to you.
The definition of “group purchaser” includes:
- Group health insurance carriers;
- Property-casualty insurance carriers;
- Workers’ compensation carriers;
- Auto carriers;
- 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.
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.