Benefit Appeals

By law, Medica must offer appeals rights to members for all previously denied services. At the request of the member or participating provider (on behalf of the member), the appeals staff conducts case review of previously denied services to ensure accurate review, and coverage of eligible services according to the member’s benefit document.

In the event of a denied prior authorization for medical necessity, for all plans except Medicare, a provider may consider one of the following two (2) options before filing an appeal on behalf of the member:

Peer to Peer Discussion

If the provider would like to discuss an initial prior authorization denial with a Medica Medical Director, the provider may request a peer-to-peer discussion by calling 1 (855) 235-0511 within 10 business days of the denial notice.

Submission of a New Prior Authorization

If the authorization is denied and there is new and/or additional objective medical documentation related to the denied service, a new prior authorization request may be submitted for consideration. The prior authorization request must contain new and/or additional objective medical documentation related specifically to the denied service for it to be considered.

Provider Appeal Process

The Clinical Appeals Department handles appeals that are related to clinical issues only. Any issues regarding coding or reimbursement need to be directed to the Provider Service Center at 1 (800) 458-5512.

Participating providers may contact the Clinical Appeals Department directly to initiate an appeal request on behalf of a member, except for members covered under Medica’s Medicare products. Any new information about a previously denied service will assist in an accurate and appropriate benefit determination. Written requests for appeal initiation should be directed to:

Clinical Appeals Department
CP420
PO Box 9310
Minneapolis, MN 55440-9310
Fax Number (952) 992-8403

It is required that prior authorization be obtained before certain services are rendered. If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. The provider will have 60 days from the date of the claim denial to appeal and supply supporting documentation required to determine medical necessity.

Claim Adjustment/Appeal Request Form

Medica reserves the right to conduct a medical necessity review at the time the claim is received.

For more information regarding the review and complaint resolution, view the Complaint Review Process

A Medica medical director is available to discuss denial decisions with participating providers. To contact a medical director, please call Utilization Management at 1 (855) 235-0511.

As stated in the Medica Participation Agreement, records or copies of records are to be released to Medica within 14 calendar days, or sooner if required to comply with regulatory, accreditation or contractual obligations. Upon enrollment, each member signs a consent form that authorizes the release of medical records. Therefore, additional consent forms are not required.

If the medical records or reports are requested due to a claim reimbursement issue, Medica does not reimburse the participating provider for copies.

REV 8/2023