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Claim Tools

Billing Related to COVID-19

Administration of Claims and Products

Adjustment and Resubmission Processes


Advance Notices for Patient Payment Liability

Claim Forms

Electronic Claims Submission

Electronic Data Interchange (EDI) 

No Surprises Act

Here are instructions and forms related to the No Surprises Act for out-of-network providers to dispute the payment rate they received from Medica (open negotiation must be exhausted prior to IDR initiation): 

These forms should be sent to:

Medica QPA Dispute Resolution
c/o HRGi
9711 Washingtonian Blvd., Suite 300
Gaithersburg, MD 20878

E-mailbox: [email protected]

Questions? Call HRGi toll-free at 1 (800) 234-1924.


Out-of-Network Appeal Forms

Recovery Processes

Referral Processes

Skilled Nursing Facility

Special Transportation

Specialty Guidelines

Timely Filing

Date: 5/26/2024 4:42:44 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01