AUC Claims DD TAG

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To create and develop common standards in cases where Medicare rules do not meet Minnesota needs and Minnesota statute 62J.536 requires providers to submit the 837 professional, 837 institutional, 837 dental and NCPDP pharmacy claims using common, uniform standards.

An overarching principle of this work is the fact that each Minnesota group purchaser and provider will be required to make changes to procedures, policies and/or systems in some way, as a result of the work of the AUC and the Claims Data Definition TAG, resulting in lowering or slowing the rise in administrative costs for the system as a whole.

• Items within the scope of the TAG are:
  • Companion rules for claim electronic submission
  • Attachments
  • Adjustments
  • Definitions
  • Forms
  • Best Practices related to claims submission
• Review the 5010 HIPAA Implementation Guides and document results in a Common Uniform Companion Guide for each of the claims transactions. The TAG will bring any items with unknown ownership to the AUC Executive Committee for proper assignment.
• Review the appropriate CMS Medicare Companion Guides related to 5010 claims submission.
• Determine consensus: If all group purchasers/providers do not agree to follow Medicare rules or such Medicare rules do not exist, then the TAG will decide on ONE way to submit the appropriate claims for business in Minnesota. All participants should provide compelling business facts to support the preferred method.
• If group purchasers/providers do not reach consensus on ONE standard for the appropriate claim type, then action items will be assigned to group purchasers/providers, with a deadline date to report back to the TAG on findings. If after reviewing the additional findings, consensus is still unable to be reached at the TAG, then all proposed standards will be documented and brought before the AUC Operations Committee for additional guidance and development of a final recommendation for Minnesota Department of Health.
• Develop front matter guidance for the 837 professional, 837 institutional, 837 dental and NCPDP pharmacy claims Minnesota Uniform Companion Guides.

Minnesota rules for claims when health plan group purchasers require different information on claims formats other than those in the CMS Medicare Manual or the standard HIPAA mandated Implementation Guides. Minnesota rules will be contained in four Uniform Companion Guides:

• MN Institutional Claims (837I) Companion Guide
• MN Professional Claims (837P) Companion Guide
• MN Dental Claims (837D) Companion Guide
• MN Pharmacy Claims (NCPDP D.0) Companion Guide

Companion Guides for 5010 are to be completed by December of 2009 with work continuing on identified best practices following completion of the Companion Guides.