Claim Tools

Administration of Claims and Products

• Claim Submission and Product Guidelines
• Medicare Paid in Error Quick Reference Guide
• Medicare Advantage Travel Benefit Information
• Primary Payer Information for Medicare and Medicaid Products

Adjustment and Resubmission Processes

• Appeal Submission Tips for Providers
• Claim Adjustment or Appeal Request Form (DOC)
• Claim Adjustment or Appeal Request Guidelines
• CMS Waiver of Liability Form
• SympliSend- Electronic Appeal Submission Tool for Payer ID 94265

Admissions

• Hospice Notification Form – Administrative Hold (PDF)
• Inpatient Admission – Notification Guidelines (PDF)
• Inpatient Notification Form (PDF)
• Mechanical Circulatory Support Devices – Notification Form (PDF)
• PMAP/MNCare Birth Notification Form (PDF)
• Prior Authorization Request Form for Post-Acute Inpatient Admissions (SNF, LTACH, Acute Rehab) (PDF)

Advance Notices for Patient Payment Liability

• CMS Information on Advance Beneficiary Notices
• Pre-Service Payment Consent Form (PDF)

Claim Forms

• Sample CMS-1500 Claim Form from the National Uniform Claim Committee (PDF)
• How to Complete the UB-04 (PDF)

Electronic Claims Submission

• AUC Initiative
• Delta Dental of Minnesota
• MN E-Connect Registration
• Out-of-Network Provider Setup Form (DOC); short instructional video on how to complete the form

Electronic Data Interchange (EDI) 

• Electronic Billing Resources for Small Providers (PDF)
• Electronic Payments and Statements – How to Register (PDF)
• Electronic Transactions – Eligibility Inquiry Helpful Hints (PDF)
• Provider Portal Registration Guide for Primary and Secondary Administrators
• User Guide for Provider Demographic Update Online Tool (PDOT) — (PDF)
• User Guide for Medica Electronic Transactions (PDF)

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): 

• Open Negotiation Notice (PDF)
• Notice of Independent Dispute Resolution (IDR) Initiation (PDF)

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

• Out-of-Network RAPL Payment Appeal Form (PDF)

Recovery Processes

• Overpayment Adjustment Guidelines (PDF)

Referral Processes

• Care System Referrals – Frequently Asked Questions (PDF)
• County Partners, Care Systems and Agencies – Phone and Fax Numbers (PDF)
• Minnesota Restricted Recipient Program (PDF)
• Referral Guidelines – Elect / Essential (PDF)
• Referral Guidelines – MSHO, MSC+, SNBC (PDF)
• Referral Guidelines – Restricted Recipient Program (DOC)
• Referral / Care Direction Form – Elect / Essential / ACO (PDF)
• Referral Request Form – Restricted Recipient Program (DOC)

Skilled Nursing Facility

• Nursing Facility Communication Form DHS 4461 Example (PDF)
• Nursing Facility Communication Form DHS 4461 eDoc

Special Transportation

• Special Transportation Guidelines, Requirements, and Certification of Need Form

Specialty Guidelines

• Dental Guide to Medical Coverage for Dental-Related Services (PDF)
• Eligible Chiropractic Codes for Commercial and Individual Plans (PDF)
• Health Care Home / Medical Home – Frequently Asked Questions (PDF)
• Housing Stabilization Services Provider FAQ (PDF)
• Medica Hearing Aid Coverage Guide (PDF)
• Rural Health Clinics and Federally Qualified Health Centers – Frequently Asked Questions (PDF)

Timely Filing

• Timely Filing and Late Claims Policy (PDF)