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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. 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℠
  • Clear Value with Medica℠
  • Medica Complete Health℠
  • Medica with CHI Health℠
  • North Memorial Acclaim by Medica℠
  • Park Nicollet and HealthPartners Medical Group First with Medica℠
  • Ridgeview Community Network® Powered 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.

Providers must submit an OON prior authorization request form located at the Medica Utilization Management and Prior Authorization page. 

  • Balance by Medica℠
  • Bold by M Health Fairview and Medica℠
  • Elevate by Medica℠
  • Empower by Medica℠ 
  • Engage by Medica℠
  • Essentia Choice Care with Medica℠ (Commercial) 
  • Essentia Choice Care with Medica℠ (Individual and Family Business)
  • Harmony by Medica℠
  • Inspire by Medica℠
  • Medica with CHI Health℠
  • Medica with Healthier You℠
  • Medica with MU Health Care℠ 
  • Ridgeview Distinct by Medica℠
  • Select by Medica℠
 

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).

If you have questions, call the Medica Provider Service Center at 1-800-458-5512 or email referralinquiry@medica.com.

 


 

REV 12/2022

Date: 1/28/2023 5:20:42 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01