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Contact Info
Minnesota Administrative Uniformity Committee
651-201-3573
health.auc@state.mn.us

Contact Info

Minnesota Administrative Uniformity Committee
651-201-3573
health.auc@state.mn.us

AUC Forms

** Do NOT send claims or any patient-identifiable information to the AUC **

Forms listed below should be sent to the appropriate payer (PDF)

(Do NOT send to the MN Department of Health or the AUC)

Claims Attachment Cover Sheet

Claims Attachment Cover Sheet (including instructions) (DOC)
NOTE: As per the instructions, submit only one provider ID number on the claims attachment cover sheet. Submission of more than one provider ID number may result in the attachment cover sheet and related attachment not being accepted.

AUC Payer Contact Information (PDF) for faxing claims attachments

Claims Appeal Request Form

Claims Appeal Request Form (PDF)

Instructions (PDF)

AUC Payer Contact Information (PDF) 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)

The form is intended primarily for use by prescribers, or those designated and authorized to act on behalf of prescribers, to:

  • Request an exception to a prescription drug formulary.
  • Request a prior authorization (PA) for a prescription drug.
Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form

Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form (PDF)

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  • ehealth
Last Updated: 12/14/2022

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