Electronic claim attachments

Requirements for claim attachment submission are standardized across Minnesota. Minnesota Health Care Programs (MHCP) requires only a limited number of claim attachments. Claims with attachments are complex claims for prompt payment purposes.

When you need to submit an electronic claim with an attachment, follow these steps:

Review the claim attachment criteria to ensure that your claim attachment is necessary.
Complete the Administrative Uniform Committee (AUC) uniform Claims Attachment Cover Sheet which is required for all attachments in Minnesota. Download it from the Minnesota Department of Health’s AUC Forms webpage. Use the AUC uniform cover sheet only for electronic claims that require an attachment. Do not use the AUC uniform cover sheet without an attachment control number (ACN) or to submit authorization requests that require attachments.
Create a unique ACN. The ACN must be unique to each claim and must not be the patient account number unless patient has new account number each visit.
Enter the unique ACN (including spaces and hyphens) on each attachment page, the cover sheet and your electronic claim. Each type of attachment must have its own completed cover sheet. On the cover sheet, enter the ACN as follows:
- Interactive: Enter the ACN(s) in the Claim Information tab, Attachment Control Number/PWK field; select the qualifier in the type field
- Batch: Enter the ACN(s) in Loop 2300, PWK06; enter the attachment type in Loop 2300, PWK01; enter the method by which you send the attachment information in Loop 2300, PWK02 (follow complete AUC Attachment Cover Sheet Instructions)
Submit the claim electronically via MN–ITS Interactive or Batch.
Fax the cover sheet and attachments to MHCP at 651-431-7786.

Providers must send the attachment by the end of next business day after submitting the electronic claim. MHCP will deny claims that do not include an attachment.

Refer to our on-demand video Sending an Attachment for a MN–ITS Claim for more information.

Claim attachment criteria

Reason for attachment: MHCP will accept the attachments as noted in the following scenarios. Please follow these criteria and attach only the additional documentation noted here.

Scenarios and required documentation

The other third party insurance has not responded to my three billing attempts within 90 days
- Keep documentation on file.
- Submit a copy or screen print of the first claim sent to the TPL payer and documentation of two further billing attempts (up to 30 days after the previous attempt).
- Send a copy of any communication you received from the TPL payer, or if no response indicate “no response received.”
- Do not complete COB information on claim.
The claim is over one year old (provider error does not qualify)
MHCP accepts claims older than one year for these reasons only:
- Member eligibility: attach county letter
- MHCP denied in error: attach explanation of error
- TPL or Medicare adjusted payment: attach explanation of benefits (EOB)
- County submits Late Request for Medicare Reimbursement (DHS-3918) (PDF)
Service requires a specific attachment (such as sterilization consent, hysterectomy statement, medical necessity statement)
Refer to these MHCP Provider Manual sections for the requirements and attach appropriate documents:
- Sterilization for Sterilization Consent Forms
- Hysterectomy for Acknowledgement Statement
- Abortion Services for Medical Necessity Statement
Dental services started but not completed: Undeliverable removable prostheses
Include the following:
- Reason for nondelivery that is noted in patient chart
- Documentation describing percentage of the procedures completed
- Any expenses incurred including a copy of any lab invoice
DT&H services approved after graduation and before 21st birthday
- For residents of ICF/DD, attach copy of DHS letter
- For members on DD waiver, do not include attachment; bill electronically with SA number
Hearing aid repair for non-contracted hearing aids or shells; re-casing; miscellaneous hearing aid services
Housing Stabilization – Transition Services Moving Expenses
- Refer to Moving Expenses on the Housing Stabilization Services policy webpage for information about moving expenses.
- Include receipts of purchased covered items
- Multiple receipts may be included on the same page for the same recipient provided they are legible and meet acceptable criteria.
Individualized Education Program (IEP) provider billing assistive technology device(s)
Attach a copy of each of the following:
- Unaltered invoice reflecting cost
- IEP plan or pages that indicate the child’s need for the device
- Assessment, if applicable
Medicare Part A benefits are exhausted (“J” claims)
- Do not complete Medicare COB information on claim
- Attach all Medicare EOBs (Part A and Part B) for dates of service
- Write “Medicare Part A Benefits Exhausted” on top of Medicare EOBs
Multiple emergency department (ED) visits for the same member to the same facility on the same day; last visit results in admit
- Submit each non-admit ED visit as a separate claim with its own cover sheet and attachment (with ACN) explaining reason for visit
- Enter discharge time on each outpatient claim
- Combine admitting ED visit with inpatient charges
Other
Overlapping MHCP and managed care organization (MCO) coverage
- Send cover sheet that states the member has dual coverage for date of service
- Attach MCO explanation of benefits (EOB)
- Update and complete the coordination of benefits (COB) information on claim
Therapeutic leave days added for members in an ICF/DD
Third-party liability (TPL) paid
TPL zero pay on a bundled claim line and TPL was reported on the MHCP claim but MHCP denied for missing plan information.
- Submit a new claim
- Update and complete the coordination of benefits (COB) information on claim
- Write “TPL zero pay on a bundled claim line” on top of the TPLs EOB
- Attach the TPL EOB to the claim
Transplant services
For professional component:
- Submit separate claims for the donor and donee using the donee’s member ID number
- Submit an attachment or note to identify the donor and the donee on each claim
Transportation claims with specific modifiers of where emergency transport is to and from
Unlisted durable medical equipment (DME) or supplies (such as K0108 or E1399)
- Require the Manufacturer's Suggested Retail Price (MSRP)
- Include invoice or catalog page