Frequently Asked Questions

Frequently Asked Questions (FAQs)

The following FAQs are provided for information and clarification. They will be revised and updated as needed. Additional information regarding Minnesota Statutes, section 62J.536 and related rules is available at on the Minnesota Department of Health Administrative Simplification Act website.

Last revised: 1/30/2012

Category 7 - Eligibility Inquiry and Response

"Electronically" means that initial eligibility inquiries and responses must exchanged either via compliant internet ("web") or "electronic data interchange" (EDI) connections. Interactive Voice Response (IVR) is not compliant for this initial exchange. If, after an initial compliant exchange (via web or EDI) additional information or review is needed, other options that may be available from payers may be used, including IVR. Many in the industry are transitioning away from the IVR systems they had made available to check eligibility and are putting into place compliant web-based and EDI alternatives. We appreciate and encourage everyone's good faith efforts in making this transition.

Yes, the 5010 eligibility transaction has been enhanced. With 5010, the payer is required to report the following data in its response to an eligibility request from a provider:

  • A monetary amount or percentage amount the patient is responsible to pay, when reporting co-insurance, co-payment, deductible, and similar information;
  • How the patient is to be identified on subsequent transactions, such as the claim;
  • The health plan name, effective dates of the health plan, and any required demographic information; and
  • Benefit information for medical care, chiropractic care, dental care, hospital, emergency services, pharmacy, professional visit—office, vision, mental health, and urgent care.

Moreover, in developing the version 5010 Minnesota Uniform Companion Guide for the Implementation of the Health Care Eligibility Benefit Inquiry and Response (270/271), the Minnesota AUC determined that payers would return additional benefit information—such as patient out-of-pocket costs and the remaining deductible—to help providers that see patients who are on high-deductible and high co-insurance health plans.

Yes, the Minnesota AUC has developed several eligibility best practices.

Updated Tuesday, 07-Apr-2020 15:08:17 CDT