Medica Administrative Manual > Health Management and Quality Improvement > Administrative Referrals/Care Direction
Administrative Referrals/Care Direction
Overview
Medica requires administrative referrals/care direction for many of its products. The three types of referrals are:
- Administrative Referral or Referral
- Care Direction
- Out of Network (OON) Prior Authorization
See below for applicable products for each referral type and overall guidelines.
Administrative Referral or Referral
Permission from the members primary care clinic (PCC) for a member to receive medically necessary care or services from a provider outside of the member’s PCC or care system when such care or services are not available within the PCC. The products this applies to include:
- Medica Elect®
- Medica Essential℠
The below plans require referrals for some services. A Medica member’s care coordinator should send the referral to Medica prior to the member receiving certain services.
- Medica DUAL Solution®/Minnesota Senior Health Options (MSHO)
- Medica Choice Care℠ MSC+/Minnesota Senior Care Plus (MSC+)
- Medica AccessAbility Solution®/Special Needs Basic Care (SNBC)
- Medica AccessAbility Solution Enhanced/Special Needs Basic Care Integrated (I-SNBC)
Care Direction
Permission from an Accountable Care Organization (ACO) for a member to receive medically necessary care or services from a provider outside of the member’s ACO care system when services are not available within the ACO, but the provider is contracted with Medica. Requests must come from the ACO via the portal or referral form. The products this applies to include:
- Altru & You with Medica℠
- Altru Prime by Medica℠
- Balance by Medica℠
- Bold by M Health Fairview and Medica℠
- Clear Value with Medica℠
- Elevate by Medica℠
- Empower by Medica℠
- Engage by Medica℠
- Essentia Choice Care with Medica℠ (Commercial and IFB)
- Harmony by Medica℠
- Inspire by Medica℠
- Medica Complete Health℠
- Medica with CHI Health℠ (Commercial and IFB)
- Medica with MU Health Care℠
- North Memorial Acclaim by Medica℠
- Park Nicollet and HealthPartners Medical Group First with Medica℠
- Ridgeview Community Network® Powered by Medica
- Ridgeview Distinct by Medica℠
- Select by Medica℠
- VantagePlus With Medica℠
Out-of-Network (OON) Prior Authorization
A request initiated by a provider referring to a provider who is not contracted with the member’s plan type. An OON request will need to be reviewed and authorized by Medica for conditions that require ongoing services from a specialist provider. OON requests will only be covered for the period of time appropriate to your patient’s medical condition. An OON request may be granted if Medica determines this is medically appropriate and care is not available within the members plan type. This guideline applies to all Medica products.
Providers must submit an OON prior authorization request form located at the Medica Utilization Management and Prior Authorization page.
Guidelines
- An administrative referral request must be authorized in advance and originated by the member’s primary care physician/clinic or care coordinator, depending on product.
- Approved referrals are valid for the date(s) of service specified on the referral request form.
- All referrals, care direction and OON prior authorizations are subject to the member’s Medica eligibility status and plan benefits for the date(s) of service indicated.
- Providers are able to obtain copies of the product specific referral/care direction guidelines under the Referral Process section of Claim Tools, or by contacting the literature request line at (952) 992-2232 or 1 (800) 458-5512 (option 1, then option 8, ext. 2-2355).
REV 12/2023