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 (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 (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(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.