MHCP Enrolled Providers

Claim Attachment Criteria

Revised 4/12/16

Follow these steps to submit electronic claims with attachments to MHCP:

1. Use this form as a checklist in conjunction with the Administrative Uniformity Committee (AUC) Uniform Cover Sheet for Health Care Claims

2. Create an attachment control number (ACN) unique to your claim that will work for your tracking purposes

3. Enter that unique ACN on each attachment page and in MN–ITS:

  • • Batch: Loop 2300, PWK 06; enter the attachment type in Loop 2300, PWK01; enter method by which you send the attachment information in Loop 2300, PWK02 (follow complete AUC Attachment Cover Sheet Instructions)
  • • Interactive: Claim Information tab, Attachment Control Number/PWK field; select the qualifier in type field

  • 4. Fax AUC Cover Sheet and attachments (not this document) to MHCP at 651-431-7786

    Reason for Attachment

    MHCP will accept the attachments as noted in the following table. Please follow these criteria and attach only the additional documentation noted here. MHCP cannot guarantee receipt of non-required attachments.

    Scenarios and required documentation

    Scenario

    Instructions

    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 over one year only for reasons below:

  • • Recipient eligibility: attach county letter
  • • MHCP denied in error: attach explanation of error
  • • TPL or Medicare adjusted payment: attach explanation of benefits (EOB)
  • Service requires specific attachment (such as sterilization consent, hysterectomy statement, medical necessity statement)

    Refer to the MHCP Provider Manual sections below for the requirements and attach appropriate document(s):

    Births between January 1, 2012, and July 31, 2012, claims for professional services performed in facilities that do not have DHS-verified policies and quality improvement processes related to elective induction of labor before 39 weeks gestation

    Attach MHCP Non-participating Facility Births Evidence-based Childbirth Program Form (DHS-6469) (PDF)

    Individualized Education Program (IEP) provider billing assistive technology device(s)

    Attach 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
  • 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 procedure(s) completed
  • • Any expenses incurred including a copy of any lab invoice(s)
  • DT&H services approved after graduation and before 21st birthday

  • • For residents of ICF/DD, attach copy of DHS letter
  • • For recipients 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

    Attach invoice

    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 recipient 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
  • 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 ICF/DD recipients

    Attach approval letter

    Unlisted DME or supplies (such as K0108 or E1399)

  • • Require the Manufacturers Suggested Retail Price (MSRP)
  • • Include invoice or catalog page
  • Transportation claims with specific modifiers of where emergency transport is to and from

    Require the ground or air checklist components to be sent

    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
  • Other

    Attach appropriate documentation (such as invoice, price list, medical notes)

    Contact Information

    MHCP Provider Call Center: 651-431-2700 or 800-366-5411

    www.dhs.state.mn.us/provider

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