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Medica Administrative Manual > Billing and Reimbursement > Claim Submission Requirements for Professional Services

Claim Submission Requirements for Professional Services

Administrative Requirements

All individuals and organizations that meet the Health Insurance Portability and Accountability Act (HIPAA) definition of a "health care provider" AND meet the definition of a "covered entity" under HIPAA are required to obtain a National Provider Identifier (NPI). Participating providers must include the NPI in box 33 on the CMS-1500 form.

The member’s Medica identification number must always be legible.

Participating providers must submit claims on the members' behalf and work directly with Medica for reimbursement. Do not ask members to submit claims for services rendered.

The sample CMS-1500 (formerly HCFA-1500) claim form indicates which fields are required (if applicable) or optional. Please refer to the “Sample CMS-1500 Claim Form from the National Uniform Claim Committee” guidelines found under Claim Forms on the Claim Tools page when submitting a claim. Correctly completing the CMS-1500 form will improve the turnaround time for payment of claims.

Deadline Information +

Timely submission of all claims is necessary for prompt reimbursement. Please refer to the below policy for claim submission, resubmission, adjustment, exception and late claim appeal requirements.

Timely Filing and Late Claims Policy (PDF)

Claim Denials +

To help avoid unnecessary claim processing denials, please review the appropriate coverage, utilization management and reimbursement policies that apply to your claim.

Medica Policies and Guidelines

Common examples of denials include, but are not limited to:

When two identical claims are received for the same service on the same date (for the same member), one will be denied as an "exact duplicate."
Claims billed with invalid or missing DX or CPT/HCPCS codes.
A new claim is submitted with information attached for a claim that is already on file.
Appropriate modifier was not billed for the service rendered.
Coverage or utilization management guidelines were not met for the services billed.
Claim not billed in accordance with current standard coding practices.

Questions regarding claim denials and issues should be directed to the Provider Service Center at 1 (800) 458-5512.

Claim Returns +

Common reasons why original claim submissions will be returned include, but are not limited to:

• Member's Medica identification number is missing or invalid for date of service.
• Participating provider’s NPI is missing or invalid.
• Referring physician's name or NPI is missing or invalid when required.
• Subscriber/member is not valid.
• Demographic information on claim does not match what Medica has on file.
• There is missing or invalid information in any of the required applicable fields designated on the sample Send-back Form below.

Please Note: "Send-back" (returned) claims will include a request that the participating provider RESUBMIT the bill as an original claim. Medica does not input or track claims that have been returned to a provider due to improper claim information. Medica maintains no information about send-back claims in its system.

Questions regarding claim send-backs should be directed to the Provider Service Center at 1 (800) 458-5512, which can clarify the information needed to resubmit a claim for processing.

Submission Information

Each claim submitted to Medica, regardless of submission method, must include information covered in this section. Claims with invalid ICD or CPT/HCPCs codes will be closed and a letter will be generated. The claim will not be sent back.

If the information provided is valid, but not accurate (e.g., an active member number is used, but it does not apply to the member who received the service), the claim may be processed, but will require a subsequent adjustment. To avoid delays, always provide the most accurate information available.

Verify Medica coverage information each time services are rendered by using Medica.com, Availity Office or by calling Provider Service Center at 1 (800) 458-5512.

For Minnesota Health Care Programs (MHCP), there are additional claim submission requirements that must be followed from the Minnesota Department of Human Services (DHS). Failure to submit claims in accordance with Minnesota DHS requirements may result in claim denial as provider liability.

Methods +

Participating providers may submit claims to Medica by:

• Paper claim: Provider mails a copy of itemized bill to Medica. Paper claims must be submitted on the CMS-1500 (formerly HCFA-1500) Claim Form—established by the American Medical Association (AMA)—or the invoice accepted by the Minnesota Department of Human Services (MDHS).

• Electronically through your clearinghouse or vendor system. (Please check with vendors to determine if they have a direct connection with Medica payer IDs.)

About electronic transaction capabilities

Guidelines +

• Submit claims for only one member and one facility per form.
• Submit one attachment, i.e. Explanation of Medicare Benefit or primary carrier’s Explanation of Benefit statement, for only one member and one provider per form.
• For paper claims, submit an original UB-04 or CMS-1500 form, and not a facsimile copy. Additionally, remove all staples, ensure print is dark enough to read and that you are using standard-size font.

Submit replacement and void transactions only after an organization determination is made on the original claim. Medica will replace or void the claim requested only if an organization determination has previously been made to the claim being replaced or voided. To see the status of a claim, log in to the Medica provider portal or call the Provider Service Center at 1 (800) 458-5512.

To ensure prompt claim processing, please mail paper claims to the applicable address found here.

Additional Resources

Providers are able to obtain information, including downloadable forms, under the Claim Form section of Claims Tools .

If providers have any questions about Medica's claim submission policy, they are encouraged to call the Medica Provider Service Center at 1 (800) 458-5512.

REV 4/2024