AUC Best Practices
Minnesota AUC best practice documents are consensus recommendations of the AUC to further standardize and harmonize health care administrative transactions for providers and group purchasers. While adoption or adherence to the best practices is voluntary, it is strongly encouraged to further reduce health care administrative burdens and costs.
The best practices below are for use with the applicable version 5010 transactions.
- Acknowledgments Best Practice Summary (PDF)
- Acknowledgments Best Practice PowerPoint Presentation (PDF)
- Acknowledgments Best Practice (PDF)
Note: The three documents above recommend the type of acknowledgments to use in a variety of situations and include examples for a number of claim and remittance scenarios.
- Reporting Health Care Home (HCH) Benefits (PDF)
- Reporting Minnesota Department of Human Services (DHS) Two Digit Major Program Code for Prepaid Medical Assistance Plans (PMAP) (PDF)
- Service Type 60 Response (active coverage, no benefits reported) (PDF)
- Reporting Termination Date for Inactive Coverage (PDF)
- Service Type Inquiry/Response (PDF)
- Reporting Restricted Recipient Program (PDF)
- Provider Eligibility Verification (PDF)
- Multiple Service Type Inquiry/Response (PDF)
- Reporting Other or Additional Payor Information (PDF)
- Reporting Funding Type (PDF)
- Payer to Payer Coordination of Benefits (COB) (PDF)
Note: MS §62J.536 does not apply to payer to payer COB.
- Formatting, Submitting Patient Control/Account Numbers (PDF)
- When to Use Taxonomy Code(s) (PDF)
- Attachments (completing and sending an attachment that is related to a submitted claim) (PDF)
Note: Claims attachments and cover sheets should be sent to the appropriate group purchaser. Do NOT send them to MDH or AUC.
- Claim Service Dates Restricted to Same Calendar Month (PDF)
- Replacement/Void Claims (PDF)
Note: Replacement claims may also be referred to as "corrected claims;" void claims may also be referred to as "cancel claims."
- Appeals (submitting an appeal by a provider to a Minnesota group purchaser) (PDF)
Note: Claims appeal request forms should be sent to the appropriate group purchaser and not MDH or AUC. The attachment cover sheet must not be sent with the appeal request form.
- Billing for Postage Services (PDF)
- Billing for Covered and Non-Covered Services (e.g. elective, cosmetic, upgrade procedures) (PDF)
- Examples for NTE and PWK Usage (PDF)
- Electronic Funds Transfer (EFT) (PDF)
Note: Revised 10-21-13 to be consistent with federal operating rules
- Reporting APR-DRGs on the v5010 ERA (835) (PDF)
- Correct reporting of CAGC & CARC to consider the claim for payment as a secondary or tertiary payer (payer of last resort) (PDF)
- ASC X12N/005010X221 Health Care Claim Remittance/Advice (835) (PDF)
- ASC X12/005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) (PDF)
- ASC X12/005010X214E2 Health Care Claim Acknowledgment (277CA) (PDF)
Overview and background
Requirement for provider notification
Federal regulations (45 CFR 156.270) specify requirements that must be followed for terminating the coverage of Health Insurance Exchange enrollees who are receiving advance payments of premium tax credits (APTC). The requirements include:
- allowing APTC enrollees a three month grace period before terminating coverage due to nonpayment of premiums*;
- the Qualified Health Plan issuer (QHP - insurer) must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period, regardless of whether the enrollee subsequently pays the premium for the first month of the grace period or not. The QHP may pend claims for services rendered to the enrollee in the second and third months of the grace period;
- the QHP must notify providers that may be affected by the enrollee’s premium payment grace period that an enrollee has lapsed in his or her payment of premiums. The notice may be exchanged via automated electronic processes, and must indicate there is a possibility that the issuer may deny payment of claims incurred during the second and third months of the grace period if the enrollee exhausts the grace period without paying the premiums in full.
Issuers are encouraged to notify all potentially affected providers as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.
*Note: In order for the APTC enrollees to be eligible for the three month grace period, the enrollees must also have previously paid at least one full month's premium during the benefit year.
Need for best practice
There is no current ASC X12 technical report specifically for the provider notification described above. The AUC developed and approved three best practices, using the transactions listed below, to be followed when satisfying the provider notification requirements above. The AUC’s best practices reflect and incorporate similar draft ASC X12 best practices.