Claim Tools

Administration of Claims and Products

• Claim Submission and Product Guidelines
• Primary Payer Information for Medicare and Medicaid Products

Adjustment and Resubmission Processes

• Appeal Adjustment Reconsideration Reference Guide (PDF)
• Claim Adjustment or Appeal Request Form (DOC)
• Claim Adjustment or Appeal Request Guidelines
• Medicare Waiver of Liability Statement (PDF)

Admissions

• Hospice Notification Form – Administrative Hold (DOC)
• Inpatient Admission – Frequently Asked Questions (PDF)
• Inpatient Admission – Notification Guidelines (PDF)
• Inpatient Notification Form (PDF)
• Prior Authorization Request Form for Post-Acute Inpatient Admissions (SNF, LTACH, Acute Rehab) (PDF)

Advance Notices for Patient Payment Liability

• CMS Information on Advance Beneficiary Notices
• Pre-Service Payment Consent Form (PDF)

Claim Forms

• Sample CMS-1500 Claim Form from the National Uniform Claim Committee (PDF)
• How to Complete the UB-04 (PDF)

Electronic Claims Submission

• Advance Claim Edits (ACE) — (PDF)
• AUC Initiative
• Availity EDI Portal
• Delta Dental of Minnesota
• HIPAA 5010 Frequently Asked Questions (PDF)
• MN E-Connect Registration
• Out-of-Network Provider Setup Form (DOC)

DME Claims

• Electronic Billing Tool for Small Providers (PDF)

Electronic Commerce

• Electronic Billing Tool for Small Providers (PDF)
• Electronic Payments and Statements – How to Register (PDF)
• Electronic Transactions – Eligibility Inquiry Helpful Hints (PDF)
• User Guide for Provider Demographic Update Online Tool (PDOT) — (PDF)
• User Guide for Medica Electronic Transactions (PDF)

Home Health Care

• Home Care Services Authorization for MHCP (PDF)

National Provider Identifier

• NPI Submission Form (PDF)

Payment Resources (for EOB/PRA/835)

• Cosmos Platform PRA (PDF)
• Provider Remittance Advice (PRA) Guide for Medica2 Platform (PDF)
• United Platform EOB (PDF)

RAPL

• Out-of-Network RAPL Payment Appeal Form (PDF)

Recovery Processes

• Overpayment Adjustment Guidelines (PDF)

Referral Processes

• Care System Referrals – Frequently Asked Questions (PDF)
• County Partners, Care Systems and Agencies – Phone and Fax Numbers (PDF)
• Referral Guidelines – Elect / Essential (PDF)
• Referral Guidelines – MSHO, MSC+, SNBC (PDF)
• Referral Guidelines – Restricted Recipient Program (DOC)
• Referral / Care Direction Form – Elect / Essential / ACO (PDF)
• Referral Request Form – Restricted Recipient Program (DOC)

Skilled Nursing Facility

• MCS and County Partners – Skilled Care Documentation Form (DOC)
• Nursing Facility Communication Form DHS 4461 Example (PDF)
• Nursing Facility Communication Form DHS 4461 eDoc
• QIO Appeal – Detailed Explanation of Non-Coverage (PDF)
• Service Authorization Process – Nursing Facility Service for MSHO, MSC+ (PDF)
• Service Authorization Process – Nursing Facility Service for SNBC (PDF)
• SNF Denial Letter – Notice of Medicare Non-Coverage (PDF)

Special Transportation

• Special Transportation Guidelines, Requirements, and Certification of Need Form

Specialty Guidelines

• Dental Guide to Medical Coverage for Dental-Related Services (PDF)
• Eligible Chiropractic Codes for Commercial and Individual Plans (PDF)
• Health Care Home / Medical Home – Frequently Asked Questions (PDF)
• Medica Hearing Aid Coverage Guide (PDF)
• Rural Health Clinics and Federally Qualified Health Centers – Frequently Asked Questions (PDF)

Timely Filing

• Timely Filing and Late Claims Policy (PDF)