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Medica Administrative Manual > Health Management and Quality Improvement > Notification Requirements

Notification Requirements

Inpatient Admissions

To ensure timely and accurate reimbursement, the hospital must notify the Utilization Management Department:

  • When a member has been admitted. (Please refer to your Medica Participation Agreement, notification of admission, for all requirements.)
  • Within 24 hours of an emergency admission (or the next business day if the admission occurs on a weekend).

The Utilization Management Department can be notified by:

  • Using the Provider Portal. For help accessing or using the Provider Portal, please use the Portal Registration User Guide for Primary and Secondary Administrators.
  • Faxing 952-992-3555
  • Calling 1-800-458-5512

For most Medica members, mental health/substance use disorder admissions can be arranged by calling Medica Behavioral Health at 1-800-848-8327. See specific details based on payer ID.

The member is responsible for notifying Medica of an emergency confinement at a nonparticipating facility as soon as it is reasonably possible by calling the Member Service number on the back of their identification card.

Exclusions

These services are excluded from coverage under in-network benefits:

  • Non-emergency care from nonparticipating providers, unless prior authorization is obtained
  • Unauthorized continued confinement in a nonparticipating facility after the attending physician determines it is safe to transfer the member to a participating facility.
  • Follow-up care from a nonparticipating provider unless prior authorization is obtained.

Concurrent review documents are the clinical indicators that support ongoing need for hospitalization and most importantly Medica's proactive involvement in coordination of post discharge services when indicated.


Discharge

Discharge Notification

To ensure timely and accurate reimbursement, the hospital must notify the Utilization Management Department when the member has discharged. The Utilization Management Department can be notified by:

  • Faxing: 1-952-992-3555
  • Calling: 1-800-458-5512

Discharge Planning

If barriers to discharge are identified, Medica will collaborate with the interdisciplinary health care team to facilitate an appropriate discharge plan, including but not limited to, home health care, skilled nursing facility (stay, durable medical equipment (DME) and/or referral to community resources.

  • A physician or facility can request case management services by calling Provider Service at 1-800-458-5512 or Care Management directly at 1-866-905-7430.
  • Case managers will partner with providers and members to ensure that discharge needs are met and to prevent discharge delays.
  • After discharge, Medica outreaches to medically complex members who are at high risk for readmission to ensure safe transition between settings of care with a goal of improving health outcomes and reducing unplanned admissions.

REV 5/2021

Date: 1/28/2023 4:15:24 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01