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Medica Administrative Manual  >  Health Management and Quality Improvement > Prior Authorization

Prior Authorization

To begin the prior authorization process, providers may submit prior authorization requests to Medica Care Management by:

  • Calling 1(800) 458-5512
  • Faxing forms to (952) 992-3556
  • Sending an electronic prior authorization form.
  • Mailing forms to:
    Medica Care Management
    Route CP440
    PO Box 9310
    Minneapolis, MN 55440-9310

Prior authorization does not guarantee coverage. Medica will review the prior authorization request and respond to the provider within the appropriate federal or state timeframes, as long as all reasonably necessary information is provided to Medica.

Prior Authorization Requirements

Prior authorization is required for selected services. For providers to obtain prior authorization, Medica requires that the following information be provided:

  1. Name and phone number of the provider who is making the request.
  2. Name, phone number, address and type of specialty of the provider to whom the patient is being referred, if applicable.
  3. Services being requested and the date those services are to be rendered (if scheduled).
  4. Specific information related to the patient’s condition (clinical rationale for service being requested).

For more information on which services require prior authorization from Medica, please review the current Prior Authorization List of medical services. Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1 (800) 458-5512, option 1, then option 8, ext. 2-2355. 

See more about prior authorization, including appropriate request forms

 

 

To find out if a member is eligible for a service, providers may call Medica’s Provider Service Center at 1(800) 458-5512.


Utilization Management

For all plans except Medicare, 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.

For all plans except Medicare, 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.

For all plans, if the provider would like to discuss any utilization management (UM) decisions with a Medica Medical Director and/or Utilization Management staff, contact Utilization Management at 1 (855) 235-0511.

For general UM inquiries, the provider may also contact Provider Services at 1 (800) 458-5512 or reference the Medica Utilization Management Policies.

It is required that prior authorization be obtained before 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.

Access the Claim Appeal Request Form

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

Please note: Medica retains the option to evaluate the need for prior authorization in situations of high utilization.



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