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Minnesota Legislature

Office of the Revisor of Statutes

62J.51 Definitions.

Subdivision 1. Scope. For purposes of sections 62J.50 to 62J.61, the following definitions apply.

Subd. 2. ANSI. "ANSI" means the American National Standards Institute.

Subd. 3. ASC X12. "ASC X12" means the American National Standards Institute committee X12.

Subd. 3a. Card issuer. "Card issuer" means the group purchaser who is responsible for printing and distributing identification cards to members or insureds.

Subd. 4. Category I industry participants. "Category I industry participants" means the following: group purchasers, providers, and other health care organizations doing business in Minnesota including public and private payers; hospitals; claims clearinghouses; third-party administrators; billing service bureaus; value added networks; self-insured plans and employers with more than 100 employees; clinic laboratories; durable medical equipment suppliers with a volume of at least 50,000 claims or encounters per year; and group practices with 20 or more physicians.

Subd. 5. Category II industry participants. "Category II industry participants" means all group purchasers and providers doing business in Minnesota not classified as category I industry participants.

Subd. 6. Claim payment/advice transaction set (ANSI ASC X12 835). "Claim payment/advice transaction set (ANSI ASC X12 835)" means the electronic transaction format developed and approved for implementation in October 1991, and used for electronic remittance advice and electronic funds transfer.

Subd. 6a. Claim status transaction set (ANSI ASC X12 276/277). "Claim status transaction set (ANSI ASC X12 276/277)" means the transaction format developed and approved for implementation in December 1993 and used by providers to request and receive information on the status of a health care claim or encounter that has been submitted to a group purchaser.

Subd. 6b. Claim submission address. "Claim submission address" means the address to which the group purchaser requires health care providers, members, or insureds to send health care claims for processing.

Subd. 6c. Claim submission number. "Claim submission number" means the unique identification number to identify group purchasers as described in section 62J.54, with its suffix identifying the claim submission address.

Subd. 7. Claim submission transaction set (ANSI ASC X12 837). "Claim submission transaction set (ANSI ASC X12 837)" means the electronic transaction format developed and approved for implementation in October 1992, and used to submit all health care claims information.

Subd. 8. EDI or electronic data interchange. "EDI" or "electronic data interchange" means the computer application to computer application exchange of information using nationally accepted standard formats.

Subd. 9. Eligibility transaction set (ANSI ASC X12 270/271). "Eligibility transaction set (ANSI ASC X12 270/271)" means the transaction format developed and approved for implementation in February 1993, and used by providers to request and receive coverage information on the member or insured.

Subd. 10. Enrollment transaction set (ANSI ASC X12 834). "Enrollment transaction set (ANSI ASC X12 834)" means the electronic transaction format developed and approved for implementation in February 1992, and used to transmit enrollment and benefit information from the employer to the payer for the purpose of enrolling in a benefit plan.

Subd. 11. Group purchaser. "Group purchaser" has the meaning given in section 62J.03, subdivision 6.

Subd. 12. ISO. "ISO" means the International Standardization Organization.

Subd. 13. NCPDP. "NCPDP" means the National Council for Prescription Drug Programs, Inc.

Subd. 14. NCPDP telecommunication standard format 3.2. "NCPDP telecommunication standard format 3.2" means the recommended transaction sets for claims transactions adopted by the membership of NCPDP in 1992.

Subd. 15. NCPDP tape billing and payment format 2.0. "NCPDP tape billing and payment format 2.0" means the recommended transaction standards for batch processing claims adopted by the membership of the NCPDP in 1993.

Subd. 16. Provider. "Provider" or "health care provider" has the meaning given in section 62J.03, subdivision 8.

Subd. 17. Uniform billing form CMS 1450. "Uniform billing form CMS 1450" means the uniform billing form known as the CMS 1450 or UB92, developed by the National Uniform Billing Committee in 1992 and approved for implementation in October 1993, and any subsequent amendments to the form.

Subd. 18. Uniform billing form CMS 1500. "Uniform billing form CMS 1500" means the 1990 version of the health insurance claim form, CMS 1500, developed by the National Uniform Claim Committee and any subsequent amendments to the form.

Subd. 19. Uniform dental billing form. "Uniform dental billing form" means the most current version of the uniform dental claim form developed by the American Dental Association.

Subd. 19a. Uniform explanation of benefits document. "Uniform explanation of benefits document" means the document associated with and explaining the details of a group purchaser's claim adjudication for services rendered, which is sent to a patient.

Subd. 19b. Uniform remittance advice report. "Uniform remittance advice report" means the document associated with and explaining the details of a group purchaser's claim adjudication for services rendered, which is sent to a provider.

Subd. 20. Uniform pharmacy billing form. "Uniform pharmacy billing form" means the National Council for Prescription Drug Programs/universal claim form (NCPDP/UCF).

Subd. 21. WEDI. "WEDI" means the National Workgroup for Electronic Data Interchange report issued in October 1993.

HIST: 1994 c 625 art 9 s 2; 1996 c 440 art 1 s 22-25; 2000 c 460 s 2,3; 2002 c 307 art 2 s 3; 2002 c 330 s 19; 2005 c 106 s 1,2