October 2015
General News
Provider credentialing, demographics e-mailboxes have changed
Medica recently streamlined its department e-mailboxes for credentialing and demographics due to an internal process change. Going forward, providers should use the following e-mail addresses to contact Medica for these respective issues.
| New e-mailbox |
When to use it |
| [email protected] |
Inquiring about demographic issues (including credentialing issues) |
| [email protected] |
Submitting requests for demographic updates (additions, terminations, changes) |
The following Medica e-mailboxes are no longer in use: [email protected], [email protected] and [email protected].
With questions about contract issues, providers should continue to use [email protected]. With inquiries about claims issues or reimbursement, providers should continue to call the Medica Provider Service Center at 1-800-458-5512.
Due by October 15, 2015:
Medica requests copy of certification for DME, O&P providers
Durable medical equipment (DME) and orthotics and prosthetics (O&P) providers need to submit current documentation of professional certification to Medica to continue as part of the Medica provider network. This also applies if the certificate previously sent to Medica has expired. DME and O&P providers should e-mail or mail a current copy of a proof of accreditation by October 15, 2015. If Medica has not received any certification, this may result in termination of the provider’s agreement with Medica.
Providers should send their certifications to the Medica Network Management e-mailbox, [email protected], or by U.S. mail to:
Medica Network Management
CP425
PO Box 9310
Minneapolis, MN 55440-9310
For DME and O&P providers, Medica accepts proof of accreditation from any of the following:
- Accreditation Commission for Healthcare, Inc.
- American Board for Certification in Orthotics and Prosthetics, Inc.
- Board for Orthotist/Prosthetist Certification
- Board of Certification in Pedorthics
- Commission on Accreditation of Rehabilitation Facilities
- Community Health Accreditation Program
- The Compliance Team, Inc.
- Healthcare Quality Association on Accreditation
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- National Academy of Social Insurance (NASI)
- National Association of Boards of Pharmacy
- National Board of Accreditation for Orthotic Suppliers
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Clinical News
Effective back to February 5, 2015:
Medica makes coverage policy change
The following benefit determination was effective beginning with February 5, 2015, dates of service. This change applies to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Low-dose CT for lung cancer screening
Medica has reviewed low-dose CT for lung cancer screening and added Current Procedural Terminology (CPT®) code 71250 for payment consideration. When used to bill for lung cancer screening, this code is reserved for use only with Medicare members. For further information, refer to Medica’s coverage policy titled “Low-Dose CT for Lung Cancer Screening.” This policy was updated in late August 2015 with this coding change effective retroactively to February 5, 2015.
The complete text of the policy that applies to the determination above is available online or on hard copy:
- See Medica’s coverage policies; or
- Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355
The importance of breast cancer screenings
Breast cancer affects one out of every eight women in the United States, killing more women than any cancer other than lung cancer. To help prevent death from breast cancer, the United States Preventive Services Task Force and U.S. Centers for Disease Control and Prevention (CDC) recommend that women 50-74 years of age get biennial mammograms.
When to start regular biennial screening for breast cancer should be an individual decision a patient makes with her provider, both before the age of 50 and at age 75 and older. In addition, women should be encouraged to have a clinical breast exam about every 3 years when they are in their 20s and 30s.
These guidelines do not apply to women with risk factors for breast cancer, such as genetic mutations or a close family history of the disease. It is unknown why women get breast cancer, but risk factors include:
- Age
- Genes, such as a family history (or carrying the BRCA gene)
- Personal factors such as the start of menses prior to age 12, not having children until after age 35, arrival of menopause after age 55, or receiving hormone replacement therapy
The decision for screenings should be shared between provider and patient. The patient and her provider should know the patient’s history and be able to make the best decisions for her about how to prevent breast cancer.
Due by October 15, 2015:
Quality complaint reports required by State of Minnesota
Medica requires its Minnesota-based network providers to submit third-quarter 2015 quality-of-care complaint reports to Medica by October 15, 2015.
The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form). Providers may send reports by fax to 952-992-3880 or by mail to:
Medica Quality Improvement
Mail Route CP405
PO Box 9310
Minneapolis, MN 55440-9310
Report forms are available by:
Note: Providers submitting a report for multiple clinics should list all the clinics included in the report. Providers who have questions about the complaint reporting process may:
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Pharmacy News
Effective October 1, 2015:
Medica to update commercial, Marketplace, MHCP drug lists
Medica has reviewed the following products, with their respective coverage status to be effective October 1, 2015, unless otherwise noted. As indicated in the table below, these changes will apply to the Medica Commercial Preferred Drug List; the new Marketplace Preferred Drug List for individual and family business (IFB) members and small group plan members who purchase health plans on state exchanges; and the Medica List of Preferred Drugs for Minnesota Health Care Programs (MHCP). The Medica MHCP formulary applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.
View the full table of changes »
Medica drug formularies are available online or on paper:
Medication request forms
A uniform formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
Effective October 1, 2015:
Medica to update drug UM policies
Medica will soon update the following drug utilization management (UM) policies, effective with October 1, 2015, dates of service.
Drug UM (prior authorization) policies — Revised
These versions replace all previous versions.
| Name |
| tocilizumab (Actemra®) |
| certolizumab pegol (Cimzia®) |
| secukinumab (Cosentyx®) |
| hydroxyprogesterone caproate injection (Makena®) |
| dextromethorphan/quinidine (Neudexta®) |
| denosumab (Prolia® and Xgeva®) |
| abatacept (Orencia®) |
| golimumab (Simponi®) |
| ustekinumab (Stelara®) |
| crizotinib (Xalkori®) |
| tofacitinib (Xeljanz®) |
| tetrabenazine (Xenazine®) |
These updated drug UM policies will be available online or on hard copy:
Effective November 1, 2015:
Medica to implement new drug UM policy
Medica will soon implement the following drug utilization management (UM) policy, effective with November 1, 2015, dates of service.
Drug UM (prior authorization) policies — New
| Name |
| tavaborle 5% (Kerydin®) |
This new drug UM policy will be available online or on hard copy:
Effective November 1, 2015:
Medica to update drug UM policy
Medica will soon update the following drug utilization management (UM) policy, effective with November 1, 2015, dates of service.
Drug UM (prior authorization) policies — Revised
These versions replace all previous versions.
This updated drug UM policy will be available online or on hard copy:
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Administrative News
Down the home stretch for ICD-10 coding implementation
22 days until go-live date arrives
The ICD-10 coding implementation is nearing final arrival in mere days. Here is a recap of key reminders from Medica regarding this important coding upgrade.
- The current timely-filing process will continue to apply for claims submitted to Medica that include ICD-10 codes, and no timely-filing extensions will be granted.
- Prior authorization requests need to include the proper diagnosis codes based on when they are submitted to Medica. Requests submitted prior to October 1, 2015, should continue to include ICD-9 codes, not ICD-10. Requests submitted on or after October 1, 2015, will need to include ICD-10 codes.
All providers must submit ICD-10 diagnosis and inpatient procedure codes beginning with October 1, 2015, dates of service (or dates of discharge). Claims without ICD-10 diagnosis and inpatient procedure codes as of that date cannot be processed and will not be accepted. ICD-9 codes will be accepted through September 30, 2015, dates of service (or dates of discharge).
As a final tip, providers are encouraged to focus on the top codes specific to their individual practice, given that the universe of ICD-10 codes is so vast.
Here are provider resources:
- CMS “Road to 10” website
- Provider resources from CMS
- “Preparing for ICD-10” at medica.com
Medica to update PCA administrative requirements guide
Effective November 1, 2015, Medica will update its administrative requirements and guidelines for personal care assistance (PCA) providers and agencies. The “Excluded Personal Care Assistance Provider Agencies” section will be updated to note that PCA agencies must not employ or enter into a business relationship with a PCA provider who has been convicted of a felony. If an employed PCA provider is subsequently convicted of a felony, the individual PCA provider must be terminated immediately. This policy change will be effective November 1, 2015, which is also when the updated guide will be posted on medica.com.
See the current Medica PCA guide »
Effective November 15, 2015:
Medica to implement new reimbursement policy
Medica will soon implement the new reimbursement policy indicated below, effective with November 15, 2015, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Multiple procedure payment reduction for diagnostic cardiovascular and ophthalmology procedures
Medica will align with the Centers for Medicare and Medicaid Services (CMS) and implement a new policy, “Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures,” effective with November 15, 2015, dates of service.
Cardiovascular services subject to reduction are services identified in the CMS National Physician Fee Schedule (NPFS) with a multiple procedure indicator of 6. For cardiovascular services, payment will be made at:
- 100 percent of the allowable amount for the technical component (TC) service ranked as primary
- 75 percent for second and subsequent TC services furnished by the same physician or another physician from the same group (same federal tax identification number, or TIN) on the same day
Ophthalmology services subject to reduction are services identified in the CMS NPFS with a multiple procedure indicator of 7. For ophthalmology services, payment will be made at:
- 100 percent of the allowable amount for the TC service ranked as primary
- 80 percent for second and subsequent TC services furnished by the same physician or another physician from the same group (same federal TIN) on the same day
The multiple procedure payment reductions (MPPRs) on diagnostic cardiovascular and ophthalmology procedures apply:
- independently to cardiovascular and ophthalmology services
- to the TC only and to the TC of global services
- when multiple services are furnished to the same patient by the same physician or another physician from the same group (same federal TIN) on the same day
The MPPRs on diagnostic cardiovascular and ophthalmology procedures do not apply to professional component (PC) services.
Services will be ranked by the CMS Total Non-Facility Relative Value Unit (RVU). Services with the highest RVU will be considered primary and services with the lower RVU will be considered secondary and subsequent.
This new policy will be available online or on hard copy:
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PPO News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (August 2015). Highlights that may be of interest to LaborCare® network providers include:
- Outpatient chemotherapy injectable drugs require prior authorization — now effective
- ICD-10 Coding Practice Tool for physicians — now available
- New Multiple Procedure Payment Reduction for Diagnostic Cardiovascular and Ophthalmology Procedures Policy — scheduled for November 2015
- Radiology Multiple Imaging Reduction Policy to be revised — scheduled for November 2015
- Multiple Procedure Policy to be revised to include multiple endoscopic procedures — scheduled for November 2015
View the August 2015 UHC provider bulletin »
UHC issues new Wisconsin Medicaid member ID cards
In August 2015, UnitedHealthcare Community Plan began issuing new member identification cards for its Wisconsin Medicaid health plan members. These cards put important contact information in the hands of these members as well as the Medica SelectCareSM providers who see them in western Wisconsin.
Note: The UHC Community Plan ID card is for reference only, as these UHC Medicaid members still need to present a valid Wisconsin Department of Health Services “ForwardHealth” ID card to providers when receiving care. Also, primary care providers are not listed on the UHC Community Plan ID card (as they are on the ID card for UHC commercial members, for example).
Features of the new UHC Community Plan ID cards include:
- The UHC Community Plan claims address on the back of the card, for providers' reference
- The member ID number reflects the member’s state-issued Medicaid ID number
- Group and member ID numbers that members can use to access their secure portal (myuhc.com/CommunityPlan)
Here’s a sample ID card:
See more UHC Community Plan information for providers »
Latest Aetna provider bulletin available online
Aetna has published its latest edition of Aetna OfficeLink UpdatesTM (June 2015). Highlights that may be of interest for SelectCare network providers include:
- Various updates to the Aetna National Precertification List — now effective
- Observation stays greater than 24 hours require precertification — now effective
- Aetna response time to appeals has changed — now effective
View the June 2015 Aetna provider bulletin »
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