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Medica Administrative Manual

The administrative manual is a resource for all clinic and facility staff, including physicians and other health care providers, nurses, and all business staff. This manual ensures that you have accurate and timely information about Medica products, programs, policies and procedures. All content included in the administrative manual is an extension of providers' administrative requirements, which all Medica network providers are contractually obligated to follow.


Administrative Manual Sections

Claim Adjustment/Appeal Guidelines: Adjustments, refunds and adjustment time frames

Claim Overpayments: Information on overpayment recovery, adjustment process and claim tools.

Claim Submission Requirements for Facilities: How to submit claims, interpret Medica's response and request adjustments.

Claim Submission Requirements for Professional Services: How to submit claims, interpret Medica's response and request adjustments.

Claim Tools: Find forms, guidelines, user guides and other useful resources related to billing and claim submission.

Coding Resources: Access to code updates, guidelines and frequently asked questions.

Coordination of Benefits (COB): How to handle COB claims and calculations, including Medicare claims.

Electronic Transactions: Log in to view eligibility, referrals, provider number inquiry and electronic provider remittance advice (EPRA). A variety of information and tools are available for real-time transactions, such as eligibility and claim status.

Fee Schedule Update and Release Policy: Guidelines for Medica fee schedule implementation for all lines of business.

Interim Rate Changes from CMS: How to notify Medica of a CMS interim rate change.

Medicare Estimation for IFB Claims: Additional information regarding Individual and Family Business (IFB) members who may be eligible for Medicare.

Payment Integrity Program: This program focuses on ensuring that claims are paid accurately.

Provider Remittance Advice/Electronic Remittance Advice: A summary of reimbursements made on submitted claims.

Reimbursement Policies: Provides payment methodology for medical and surgical services and supplies.

Timely Filing (PDF): Submissions, resubmissions, adjustments, exceptions and late claim appeals

Information on compliance training, Medica's Compliance Program, Special Investigations Unit (SIU), credible allegation of fraud, Restricted Recipient Program, and how to report fraud and abuse.

View Compliance and Fraud, Waste and Abuse

Administrative Referrals/Care Direction: Definitions, guidelines, request process and requirements.

Appointment Access and Office Wait Time: Acceptable time standards for patients making appointments and for wait times in the office.

Care Management: Information on Adult Complex Case Management, Advanced Illness Program, Behavioral Health Program, Benefit Appeals, Disease Management Program, Kidney Care Program, Pediatric Case Management, Pregnancy Program, Tobacco Cessation Program, Transitions of Care Program, and Transplant Case Management.

Centers of Excellence: Information on this program and access to a list of approved providers. Includes bariatric care and transplant programs. 

Clinic Site Survey: Procedures for conducting a practitioner office site-related complaint survey.

Medical Policies: Find current versions of Medica utilization management (UM) policies, coverage policies, drug management policies, reimbursement policies, and clinical guidelines. 

Medical Record Review: Examination and improvement of medical practice performance.

Member Rights and Responsibilities: Outlines Medica members' legal rights and responsibilities.

Notification Requirements: Requirements and exclusions for inpatient services.

Prior Authorization: Request process, requirements and utilization management. 

Quality Guidelines and Improvement: Encompasses a wide range of clinical and service quality initiatives.

Reporting Obligations: Find information and forms intended for Medica network providers to use in responding to reporting obligations required by law, contract or accreditation standards (including those required by the National Committee for Quality Assurance, or NCQA®).

Our network management team is available to:

  • Negotiate a provider contract
  • Provide education, including a high-level product overview and information regarding available resources
  • Respond to questions related to provider reimbursement (i.e. contracted rates and fee schedules)

Credentialing and Demographic Changes: Complete credentialing information and submit demographic change requests. 

Join the Medica Provider Network:  Detailed information on how to become contracted with Medica.

Mental Health/Substance Use Disorder (SUD) Services: Working with United Behavioral Health to provide Mental Health/Substance Use Disorder (SUD) services and disclosure requirements for SUD information.

Network Management Overview: Network development, providing contracting coordination and competitive financial arrangements.

Pharmacy policies and procedures, pharmacy related announcements and the drug lists.

View Pharmacy Services

Benefit information and overviews for each of our products, including ID card information and network restrictions.

View Product Portfolio 

Advance Directives: Information on the impact on health care providers and Medica.

Complaint Review Process: Overview of state and federal laws governing HMOs and insurance companies, including Medica's member complaint resolution process.

Continuity of Care: Requirements for notifying Medica of members' continuity-of-care needs.

Disclosure of Ownership and Excluded Entities: Find information about this disclosure requirement and the related form to complete and submit to Medica annually.

HIPAA Business Associate Requirements for Providers: Detailed information for the Privacy Rule from the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Medical Record Guidelines: Guidelines for documentation in members' medical records.

Medical Record Requests: Explanation of requirements when Medica requests medical records from a provider 

Notification of Practitioner or Clinic Termination: Requirements for notifying affected Medica Members and Medica in the event a practitioner leaves the clinic or otherwise becomes unavailable to Medica’s Members, a clinic or a clinic’s site closure, or when the Provider Participation Agreement between the parties is terminated.

Participation in Reviews and Audits: Information about Medica's quality improvement activities and studies.

Provider Privacy Policy: Information around HIPAA and other privacy practices. 

Termination of Health Services by a Provider: Procedures for notifying Medica of intention to discontinue health services to the member.

General Contracting Requirements (PDF): Additional contracting requirements for all providers

Government Program Requirements: Requirements that apply to Medica's Medicare and Minnesota Health Care Program products, as well as contracts with Minnesota Department of Human Services

Interpreter Services: Information and requirements for providers of interpreter services

Personal Care Assistance (PCA): Administrative and billing requirements for agencies that provide PCA services

Provider Protocols: Medica's general and payment protocols for contracted providers

Qualified Health Plan (QHP) Requirements: Regulatory and contractual obligations for providing health services to members of Qualified Health Plans, including Addendum for Indian Health Care Providers

Special Transportation: Certification requirements

State-Specific Contract Requirements: Requirements for providers located in the following states:

Subrogation and Recovery: Information on recovery of expenses from third parties

Telehealth: Information on telehealth, requirements for coverage and provider assurance statement

Affiliate Provider Manuals

Medica’s Affiliate Provider Manuals are for entities that are subsidiaries that directly or indirectly control, are controlled by, or are under common control with Medica. Refer to the member ID card for appropriate provider manual. Affiliate Provider Manuals include:

Dean Health Plan by Medica

Prevea360 Health Plan

Medica Central (formerly WellFirst Health)

Date: 5/26/2024 3:49:33 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01