Skip to Main Content
Providers

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 952-992-3556 or 952-992-3554.
  • Sending an electronic Prior Authorization Form.
  • Mailing it 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. 

Prior Authorization list (PDF)

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

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 (800) 292-2455. 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 here

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.


REV 4/2021

Date: 1/28/2023 4:13:53 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01