Claim Overpayments

Medica routinely reviews paid claims to identify overpayments made to a provider. An overpayment is an amount paid by Medica to a provider that exceeds the negotiated reimbursement rates agreed to in accordance with the provider participation agreement and the member's benefit plan. Examples of overpayments include, but are not limited to: (1) provider billing or claims processing errors, (2) duplicate payment for the same service, (3) payments for health services planned but not performed or for non-covered health services, (4) changes due to a member's eligibility including coordination of benefits.

See a full overview of timeframe guidelines related to overpayment adjustments.

Adjustment Process for Overpayments

After Medica identifies an overpayment, the provider is notified of the overpayment in one of two ways:

Via a Provider Remittance Advice (PRA) on which an offset of the overpayment has been made via down-adjustment of the erroneous claim (claim reason code identifies cause of overpayment) or
Via an overpayment letter, explaining the cause of the overpayment and requesting a refund. Providers may call the number on the overpayment letter if they have questions.

Provider identifies a potential overpayment

Providers who identify a potential overpayment should complete the Claim Adjustment/Appeal Request Form and submit supporting documentation to:

For Medica members with Payer ID #12422 or 41822, send the Claim Adjustment/Appeal Request Form with supporting documentation to:

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

For Medica members with Payer ID #71890, 53589 or 88090, send the Claim Adjustment/Appeal Request Form with supporting documentation to:

Medica Health Plan Solutions
PO Box 211435
Eagan, MN 55121-0051

For Medica members with Payer ID #MEDM1, send the Claim Adjustment/Appeal Request Form with supporting documentation to:

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

The Claim Adjustment/Appeal Request Form and documentation will be reviewed. If Medica determines an adjustment is necessary, providers will be notified on their next PRA or by a refund request letter.

Download the Adjustment/Appeal Request Form

Provider sends a refund check

To send a refund check use the following process:

Providers should follow the above process when identifying an overpayment. In the event that Medica requests a refund, checks should be sent to the applicable address below:
- For Medica members with Payer ID #12422 or 41822, send checks to:
  Medica Individual & Family Business
  Route CW299
  PO Box 9310
  Minneapolis, MN 55440-9310
- For Medica members with Payer ID #71890, 53589 or 88090, send checks to:
  Medica Health Plan Solutions
  Route CW299
  PO Box 9310
  Minneapolis, MN 55440-9310
- For Medica members with Payer ID #MEDM1, send checks to:
  Medica Government Programs
  Route CW299
  PO Box 9310
  Minneapolis, MN 55440-9310
- For Medica members with Payer ID #94265, send checks to:
  Medica
  PO Box 30990
  Salt Lake City, UT 84130
Medica Field Service will process the adjustment based on receipt of the refund check.
Provider will see the adjustment on the next PRA.

Provider returns a Medica check

To return a check to Medica use the following process:

Provider receives payment from Medica and after review of the payment, determines that payment has been made in error.
Provider should send the Medica check back to the applicable Salt Lake City or Minneapolis address listed above with supporting documentation indicating the payment was in error.
Medica will void the check and re-issue the correct amount as appropriate.

Additional Resources

Providers are able to obtain additional information, including downloadable forms on medica.com at Providers> Administrative Resources> Claim Tools (under the Adjustment and Resubmission Processes.

Claims tools

REV 1/2024