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Medica Claim Submission and Product Guidelines

Select the appropriate Payer ID below to view Medica claim submission and product guidelines for each plan.

Address for Claims and Claim Appeals
Medica
PO Box 30990
Salt Lake City, UT 84130-0990
Attachment/Appeal Fax#

1-801-994-1076

Claim Adjustment or Appeal Request Form (DOC)

Electronic Appeal Submission  Log in to SympliSend
Claim Numbers

5 digit groups: Claim numbers are 10 digits (CMS-1500) and 11 digits (UB-04);

6 digit groups: Claim numbers are 12 digits

Electronic Data Interchange (EDI)
Optum Intelligent EDI
Electronic Funds Transfer (EFT) Payments Optum Health Financial Services
1-866-842-3278, option 5

Prior Authorization Submission

Prior Authorization submitted via email and/or fax number provided on the corresponding form

Inpatient Notification Submission Medica.com Provider Portal/Admission Notification
Inpatient Admission – Notification Guidelines
Referral Submission Medica.com Provider Portal/Administrative Referral Entry for referral-based products
Clinical Guidelines
Policies and Guidelines on Medica.com
Provider Service Center

1-800-458-5512 

Pharmacy
BIN/PCN/Group # vary by product – see member's ID card
Chiropractic Care

Medica
PO Box 30990
Salt Lake City, UT 84130-0990
Payer ID: 94265

Benefits/Claims: Medica – 1-800-458-5512
Authorizations: Optum – 1-800-873-4575

Eligible Chiropractic Codes for Commercial and Individual Plans Only

Behavioral Health

Medica Behavioral Health (MBH): 1-800-848-8327

Medica Behavioral Health
PO Box 30757
Salt Lake City, UT 84130

Payer ID: 87726

Secure Provider Portal

Medica.com - Electronic Transactions

Product Fact Sheets

Altru & You With Medica
Clear Value With Medica
Essentia Choice Care with Medica (Commercial)
Medica Choice Passport
Medica CompleteHealth
Medica Elect and Medica Essential
Medica Focus
Park Nicollet First with Medica
Ridgeview Community Network powered by Medica
VantagePlus with Medica
Medica AccessAbility Solution / Special Needs Basic Care (SNBC)
Medica AccessAbility Solution Enhanced / Special Needs Basic Care (SNBC SNP)
Medica Dual Solution/Minnesota Senior Health Options (MSHO)
Medica Choice Care MSC+/Minnesota Senior Care Plus (MSC+)
Medica Prime Solution
Medica Select Solution
Medica Signature Solution
University of Minnesota

Address for Claims and Claim Appeals

Medica Individual & Family Business
PO Box 21051
Eagan, MN 55121-0051

Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “member not on file”

Attachment/Appeal Fax#

1-952-992-1427

Claim Adjustment or Appeal Request Form (DOC)

Electronic Appeal Submission Log in to Medica Provider Portal 

Claim Numbers

11 digits

 Electronic Data Interchange (EDI)

Availity Client Services: 1-800-282-4548

Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “invalid eligibility for member”

Electronic Funds Transfer (EFT) Payments

InstaMed: 1-866-945-7990
Email: [email protected]

Website:
Register
Login

Prior Authorization Submission

Prior Authorization submitted via email and/or fax number provided on the corresponding form

Inpatient Notification Submission Fill out the Inpatient Notification Form on Medica.com
Inpatient Admission – Notification Guidelines

Clinical Guidelines

Policies and Guidelines on Medica.com

Provider Service Center

1-800-458-5512 

Pharmacy

ExpressScripts (ESI). BIN/PCN/Group # vary by product — see member's ID card

Chiropractic Care

Optum Chiropractic
PO Box 212
Minneapolis, MN 55440-0212

Payer ID: 41161

Benefits/Claims – Medica: 1-800-458-5512

Authorizations/treatment plans are not required

Eligible Chiropractic Codes for Commercial and Individual Plans Only

Behavioral Health

Medica Behavioral Health (MBH): 1-800-848-8327

Medica Behavioral Health
PO Box 30757
Salt Lake City, UT 84130

Payer ID: 87726

Secure Provider Portal Medica.com – Electronic Transactions

Product Fact Sheets

Altru Prime by Medica
Balance by Medica
Bold by M Health Fairview
Elevate by Medica
Empower by Medica
Engage by Medica
Essentia Choice Care with Medica (Individual and Family Business)
Harmony by Medica
Inspire by Medica
Medica Applause
Medica Connect
Medica Direct HSA
Medica Direct Value
Medica Encore
Medica Individual Choice
Medica Insure
Medica Pinnacle
Medica Quest
Medica Solo
Medica Symphony HSA
Medica with CHI Health
Medica with MU HealthCare
North Memorial Acclaim by Medica
Ridgeview Distinct by Medica
Select by Medica

Address for Claims and Claim Appeals (paper submission and correspondence)

Medica
PO Box 211435
Eagan, MN 55121

Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “member not on file” 

Attachment/Appeal Fax#

952-992-3024

Claim Adjustment or Appeal Request Form (DOC)

 Electronic Appeal Submission   Log in to Medica Provider Portal.

Claim Numbers

13 digits

Electronic Data Interchange (EDI)

Availity Client Services: 1-800-282-4548
 

Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as  “invalid eligibility for member” 

Electronic Funds Transfer (EFT) Payments

InstaMed: 1-866-945-7990
Email: [email protected]

Website:
Register
Login

Prior Authorization Submission

Prior authorization submitted via email and/or fax number provided on the corresponding form

Inpatient Notification Submission Fill out the Inpatient Notification Form on Medica.com
Inpatient Admission – Notification Guidelines

Clinical Guidelines

Policies and Guidelines on Medica.com

Provider Service Center

1-800-458-5512 

Pharmacy

Varies by product – see member's ID card

Chiropractic Care

Varies by product – see member's ID card

Note: Effective 1/1/2024, chiropractic claims for Mayo and Medica Health Plan Solutions products in MN/WI should be submitted to EDI# LNDMK or Fulcrum Health, Inc. P.O. Box 981808, El Paso, TX 79998-1808. This information is not reflected on the ID Card. Questions? Contact Fulcrum at 1 (877) 886-4941, option 9, or by e-mail at [email protected].

Behavioral Health

Any provider within the available networks (see applicable provider fact sheet below for directory). 

Secure Provider Portal Medica.com – Electronic Transactions

Product Fact Sheets

Mayo Medical Plan
Medica Choice National
Medica with CHI Health Fact Sheet (Accountable Care System Product)
Medica Health Plan Solutions

Address for Claims and Claim Appeals (paper submission and correspondence)

Medica
PO Box 211435
Eagan, MN 55121

BCBS AZ providers submit to payer ID 53589

Mayo Clinic providers submit to payer ID 71890

Attachment/Appeal Fax#

952-992-3024

Claim Adjustment or Appeal Request Form (DOC)

Claim Numbers

13 digits

 Electronic Appeal Submission   Log in to Medica Provider Portal.

Electronic Data Interchange (EDI)

BCBS AZ providers submit to payer ID 53589
Mayo Clinic providers submit to payer ID 71890

Electronic Funds Transfer (EFT) Payments

InstaMed: 1-866-945-7990
Email: [email protected]

Website:
Register
Login

Prior Authorization Submission

Prior Authorization submitted via email and/or fax number provided on the corresponding form

Inpatient Notification Submission Fill out the Inpatient Notification Form on Medica.com
Inpatient Admission – Notification Guidelines

Clinical Guidelines

Policies and Guidelines on Medica.com

Provider Service Center

1-800-458-5512

Pharmacy

Alluma

1-833-789-5310

BIN/PCN/Group # vary by product – see see member's ID card

Chiropractic Care

BCBS AZ provider network

Payer ID: 53589

Behavioral Health

BCBS AZ provider network

Payer ID: 53589

Secure Provider Portal

Medica.com – Electronic Transactions

Product Fact Sheet

Mayo Medical Plan AZ

Claim Address (paper submission and correspondence)

Zelis/Medica
PO Box 2839
Farmington Hills, MI 48333

Zelis providers submit to payer ID 88090

Mayo Clinic providers submit to payer ID 71890

Address for Claim Appeals

Medica
PO Box 211435
Eagan, MN 55121

Attachment/Appeal Fax#

952-992-3024

Claim Adjustment or Appeal Request Form (DOC)

 Electronic Appeal Submission   Log in to Medica Provider Portal.

Claim Numbers

13 digits

 Electronic Data Interchange (EDI)

Zelis providers submit to payer ID 88090
Mayo Clinic providers submit to payer ID 71890

Electronic Funds Transfer (EFT) Payments

InstaMed: 1-866-945-7990
Email: [email protected]

Website:
Register
Login

Prior Authorization Submission

Prior Authorization submitted via email and/or fax number provided on the corresponding form

Inpatient Notification Submission Fill out the Inpatient Notification Form on Medica.com
Inpatient Admission – Notification Guidelines

Clinical Guidelines

Policies and Guidelines on Medica.com

Provider Service Center

1-800-458-5512

Pharmacy

Alluma

1-833-789-5310

BIN/PCN/Group # vary by product – see member's ID card

Chiropractic Care

Zelis provider network

Zelis/Medica
PO Box 2839
Farmington Hills, MI 48333

Payer ID: 88090

Behavioral Health

Any available provider within the Zelis network

Zelis/Medica
PO Box 2839
Farmington Hills, MI 48333

Payer ID: 88090

Secure Provider Portal

Medica.com – Electronic Transactions

Product Fact Sheet

Mayo Medical Plan FL

Address for Claims and Claim Appeals

Medica Government Programs
PO Box 21342
Eagan, MN 55121-0342

Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “member not on file”

Attachment/Appeal Fax#

952-992-3899

Claim Adjustment or Appeal Request Form (DOC)

 Electronic Appeal Submission  Log in to Medica Provider Portal.

Claim Numbers

13 digits

Electronic Data Interchange (EDI)

Availity Client Services: 1-800-282-4548
 

Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “invalid eligibility for member” 

Electronic Funds Transfer (EFT) Payments

InstaMed: 1-866-945-7990
Email: [email protected]

Website:
Register
Login

Prior Authorization Submission

Prior Authorization submitted via email and/or fax number provided on the corresponding form

Inpatient Notification Submission Fill out the Inpatient Notification Form on Medica.com
Inpatient Admission – Notification Guidelines

Clinical Guidelines

Policies and Guidelines on Medica.com

Provider Service Center

1-800-458-5512

Pharmacy

Medicare Advantage Solution: 

Rx Bin: 003858
Rx PCN: MD
Rx Group: 2Medica

Medicaid Families and Children: 
Rx Bin: 003858
Rx PCN: MA
Rx Group: 3Medica

Chiropractic Care

Benefits/Claims – Medica: 1-800-458-5512

Authorizations – Optum: 1-800-873-4575

Optum Chiropractic
PO Box 212
Minneapolis, MN 55440-0212

Payer ID: 41161

Behavioral Health

Medica Behavioral Health (MBH): 1-800-848-8327

Medica Behavioral Health
PO Box 30757
Salt Lake City, UT 84130

Payer ID: 87726

Dental (Medicaid Families and Children only) Delta Dental 
PO Box 9120
Farmington Hills, MI48333-9120
Payer ID: 07000
Secure Provider Portal Medica.com – Electronic Transactions

Product Fact Sheets

Medica Advantage Solution HMO Fact Sheet
Medica Advantage Solution HMO-POS Fact Sheet
Medica Advantage Solution and Medica Advantage PPO Fact Sheet
Medica Choice CareSM PMAP & Medica MinnesotaCare Fact Sheet

Address for Claims and Claim Appeals

Medica
PO Box 211404
Eagan, MN, 55121

Attachment/Appeal Fax#

Fax to 952-992-2836 or E-Mail to [email protected]

Utilization Management and Clinical Appeals
PO Box 9310
CP440
Minneapolis, MN 55440

 Electronic Appeal Submission

Dean Health Plan: providerauth.deancare.com

Prevea360: providerauth.prevea360.com

Medica (formerly known as WellFirst): providerauth.mo-central.medica.com

Claim Numbers

Claim numbers are 13 digits

Electronic Data Interchange (EDI)

Availity Client Services: 1-800-282-4548

 

Electronic Funds Transfer (EFT) Payments

InstaMed: 1-866-945-7990
Email: [email protected]

Website:
Register
Login

Prior Authorization Submission

Prior authorization submission details can be found here:
Dean Health Plan: www.deancare.com/providers/medical-management
Prevea360: www.prevea360.com/Providers/Med-Management
Medica (formerly known as WellFirst): www.mo-central.medica.com/Providers/Medical-Management

Inpatient Notification Submission Does not apply to payer 41822
Referral Submission Does not apply to payer 41822

Clinical Guidelines

Dean Health Plan: www.deancare.com/providers/medical-management
Prevea360: www.prevea360.com/Providers/Med-Management
Medica (formerly known as WellFirst): www.wellfirstbenefits.com/Providers/Medical-Management

Provider Service Center

1-800-458-5512

Pharmacy

Navitus: 866-333-2757
BIN/PCN/Group # vary by product – see member's ID card

Chiropractic Care

Medica
PO Box 211404
Eagan, MN, 55121
Payer ID: 41822

Benefits/Claims/Authorizations: Medica – 1-800-458-5512

Behavioral Health

Medica
PO Box 211404
Eagan, MN, 55121
Payer ID: 41822

Benefits/Claims/Authorizations: Medica – 1-800-458-5512

Product Fact Sheets

Dean Health Plan Focus EPO Fact Sheet
Dean Health Plan HMO Fact Sheet
Medica (formerly WellFirst Health) Fact Sheet
Prevea360 Fact Sheet

Date: 4/15/2024 10:09:28 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01