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Provider_Medica Connections


November 2015

General News | Clinical News | Pharmacy News | Network News | Administrative News | PPO News




General News


Effective January 1, 2016:
Medica to serve more MHCP enrollees in 2016
         Changes coming to Medica PMAP, MinnesotaCare service area

This summer, the Minnesota Department of Human Services (DHS) announced results of its Request for Proposals to provide health care services to Prepaid Medical Assistance Program (PMAP) and MinnesotaCare recipients in Minnesota’s 87 counties. These statewide changes will be effective on January 1, 2016.

Medica will be a health plan choice for PMAP and MinnesotaCare recipients in the seven-county metro area, plus Wright County; most counties in southern Minnesota; Lake of the Woods, St. Louis and Wadena counties to the north; and Todd and Morrison counties in central Minnesota. In all, Medica will be a plan option in 45 counties for PMAP and 55 counties for MinnesotaCare. See a map of Medica plans by county.

“We are excited to welcome new state enrollees to Medica, and we look forward to providing them with our high level of service,” said Geoff Bartsh, vice president and general manager for Medica State Public Programs.

“In addition, we are committed to continuing to provide the best service possible to our current Medica PMAP and MinnesotaCare members,” Bartsh said. “Where necessary, we will support their transition to a new health plan in the most seamless way possible. We understand the disruption that losing a health plan can mean for providers and patients.”

While Medica will not be a health plan option for PMAP and MinnesotaCare in many current northern and central counties in 2016, this does not affect Medica members enrolled in Minnesota Senior Care Plus (MSC+), Minnesota Senior Health Options (MSHO) or Special Needs Basic Care (SNBC) programs. Medica will continue its relationships with providers, county staffs and community partners to ensure that these members receive the exemplary service from Medica that they have come to expect.


Effective January 1, 2016:
Medica to offer new IFB product in Iowa, Nebraska

Medica is expanding its service area for individual and family business (IFB) plans. Effective January 1, 2016, Medica will offer the new IFB product “Medica InsureSM” in both Iowa and Nebraska, both on and off the federal Marketplace exchanges in these two states. The same plan design options will be available for Medica Insure that Medica offers with Medica Applause in North Dakota and Wisconsin. These include gold, silver, bronze and catastrophic benefit levels in both copay and health savings account (HSA) plans. Specific covered services will vary based on the essential health benefit set in each state.

Medica Insure members will access the Midlands Choice network in Iowa and Nebraska. If a Medica Insure member with this new IFB product seeks care at a provider location in Minnesota, North Dakota, South Dakota or western Wisconsin, the provider will be reimbursed according to the provider’s Medica Individual ChoiceSM rates. Providers that have contracts with both Medica and Midlands Choice will be reimbursed at their Medica Individual Choice rates.

For more details about this product, see the Medica Insure Fact Sheet.


Medica to expand its inpatient concurrent review program
         Use of MCG Care Guidelines to also expand

Beginning with December 1, 2015, dates of service, Medica will expand the use of MCG Care Guidelines® to determine appropriateness of admission to, and continued stays for, a skilled nursing facility (including an extended care facility, hospital swing-bed, and transitional care unit). MCG guidelines may be used to review medical criteria for all Medica members.

Then beginning with January 1, 2016, dates of service, Medica plans to expand its existing concurrent review program to include prior authorization and concurrent review for admission to all rehabilitation facilities and long-term acute care hospitals. With this change, MCG Care Guidelines, which are national standardized evidence-based criteria, will be used to determine admission and continued-stay appropriateness.

Beginning with January 1, 2016, dates of service, Medica will no longer cover acute rehabilitation and long-term acute care services that do not meet medical criteria. Review of these services will occur prior to admission, concurrently or retrospectively to determine if medical necessity criteria were met. As a result, claims for these services may be denied as provider liability as of January 1 (unless the member has signed an acknowledgment of member liability).

Medica will soon implement two new utilization management (UM) policies that apply to the changes above. These policies, which require prior authorization, will be available effective January 1, 2016. By instituting prior authorization, Medica aims to support members and providers in making evidence-based decisions about appropriate, medically necessary care. These changes above will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage. For example, these changes will not apply to Medica Medicare products, which will continue to follow National Coverage Determinations (NCD) guidelines.

As of January 1, 2016, the Medica Prior Authorization List will also be updated to reflect the changes above. As a reminder, Medica requires that providers obtain prior authorization before rendering services. 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.

Medica began concurrent review of inpatient stays (i.e., "bed days") at selected Minnesota facilities in fall 2014 and expanded this program to all facilities in April 2015. Medica nurse case reviewers continue to monitor appropriateness of care, the setting, and the progress of discharge plans for Medica members who are inpatients using MCG Care Guidelines. For more information, see the Medica utilization management (UM) policy titled “Inpatient (Hospital) Level of Care.

As a reminder, notification of inpatient admission is required. To ensure timely and accurate reimbursement, hospitals must notify Medica when admission and discharge occurs.

In all cases, timely requests for prior authorizations, as well as timely notifications and responses to Medica’s requests for medical records, help ensure timely review and communication of determinations back to the facility. Medica may review health services prospectively, concurrently or retrospectively to determine if medical necessity criteria were met. In any case, after Medica reviews services, claims may be denied as provider liability if facilities have not met medical criteria.

(Update to "Medica to expand existing concurrent review program" article in the March 2015 edition of Medica Connections. See March 2015 edition.)


Reminder:
Medica changes credentialing, demographics e-mailboxes

In September 2015, Medica streamlined its department e-mailboxes for credentialing and demographics as the result of 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
MedicaDemoResolution@medica.com Inquiring about demographic issues (practitioner or site issues)
MedicaDemoFormSubmis@medica.com Submitting ATC form for additions, terminations, or changes; submitting delegated reports; and sending initial credentialing applications or re-appointment credentialing applications (although the preferred method is to submit using ApplySmart)

Note: The preferred method to submit demographic updates (additions, terminations and changes) is to continue to use the Provider Demographic-update Online Tool (PDOT).

The following Medica e-mailboxes are no longer in use: CredInfoRequests@medica.com and DemographicChangeRequests@medica.com.

With questions about contract issues, providers should continue to use NetManQuest@medica.com. With inquiries about claims issues or reimbursement, providers should continue to call the Medica Provider Service Center at 1-800-458-5512.


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Clinical News


MBH available for pediatric consultations on autism disorder
         Pediatricians: Medica Behavioral Health available to help!

Parents often utilize their pediatrician as a starting point for concerns about their child’s emotional, social and behavioral well-being. This includes concerns parents may have about Autism Spectrum Disorder (ASD). Primary care offices may see these children in daily practice and feel a thorough assessment by a mental health professional would be beneficial.

Medica Behavioral Health (MBH) has a team of Care Advocates who are licensed mental health professionals specializing in children and adolescents. These Care Advocates are able to help pediatric offices and their Medica patients connect with ASD services in the Medica network. This may include assessment and ongoing treatment for ASD and any other mental health issues they may be experiencing. In addition, MBH Care Advocates can assist Medica members who qualify for the current Minnesota Department of Human Services (DHS) rollout of the Early Intensive Developmental and Behavioral Intervention benefit.

Coordination of care is vital for children and adolescents with ASD. Medica has made it a priority to work closely with its provider network to ensure that these members and their families receive the care they need. Pediatric practices are invited to call Medica Behavioral Health to collaborate and consult on a plan for any patients who need behavioral health assistance, or can refer parents to call directly. The MBH Child and Adolescent Care Advocacy team can be reached by calling 1-800-848-8327.

MBH Care Advocates look forward to working together to address the health needs of Medica members.


Proper care can prevent two major complications of diabetes
         Preventing diabetic neuropathy, nephropathy

Efforts to support patients with their diabetic management are important to prevent complications. For instance, diabetic neuropathy and nephropathy are known complications of diabetes. Diabetic neuropathy is nerve damage caused by diabetes. Nephropathy is a condition, also caused by diabetes, resulting in damage to the kidneys and possibly leading to kidney failure.

Health impacts
A major cause of diabetic neuropathy is a patient’s blood sugars not being in good control. The National Institutes of Health (NIH) and the National Institute of Diabetic and Digestive and Kidney Disease (NIDDK) estimate that about 60-70 percent of people with diabetes have some form of neuropathy or nerve damage. Lack of blood sugar control is a big factor that contributes to neuropathy in those with diabetes. People with diabetes can develop neuropathy at any time and at any age. And the longer a person has diabetes, the greater the risk of developing neuropathy.

There are several types of diabetic neuropathy: Peripheral neuropathy, autonomic neuropathy, proximal neuropathy and focal neuropathy. Neuropathy can affect the patient in a variety of ways. Peripheral neuropathy causes pain, tingling, numbness in feet and lower legs that can be debilitating. This can increase the possibility of injuries to the foot, ulcers or lesions that may become infected. Autonomic neuropathy can cause digestive issues, bowel, bladder and sexual dysfunctions. Proximal neuropathy causes pain in thighs, hips and buttocks and leads to weakness in legs. Focal neuropathy results in sudden weakness of one nerve group and can affect any nerve in the body.

Diabetes can also significantly affect the kidneys. Diabetic nephropathy is typically defined by microalbuminuria (small amounts of protein in the urine). Other complications of diabetic nephropathy may include blood pressure problems and swelling in the feet and ankles.

Proper care
The goal of treating diabetic neuropathy is to prevent further tissue damage and relieve discomfort. The most effective way to prevent this potential and likely complication of diabetes is to keep blood glucose levels as close to normal as possible. If blood sugars are controlled, the progression may be halted and symptoms may slowly improve. Maintaining safe blood-glucose levels protects nerves throughout the body.

Treatments to reduce complications from nephropathy include management of blood pressure if greater than 130/80, reducing lower-extremity edema, managing high cholesterol, and reducing risks of infection.

In order to prevent complications from diabetes such as neuropathy and nephropathy, providers need to encourage patients to do the following:

  • Follow their diabetic diet
  • Check their blood sugars
  • Take special care of their feet, wear proper-fitting shoes, and routinely check their feet for cuts and infection

Providers can also consider the following steps for these patients, as needed:

  • Consider medication options to control pain and discomfort associated with neuropathy
  • Schedule routine monitoring of A1C
  • Order annual testing of microalbuminuria levels

Effective December 1, 2015:
Medical policies and clinical guidelines to be updated

Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective December 1, 2015, unless otherwise noted.

UM policies — Revised
These versions replace all previous versions.

Name Policy number
Adult Gender Reassignment Surgery III-SUR.20
Genetic Testing for Hereditary Breast and/or Ovarian Cancer (BRCA 1 and BRCA 2 Genes and BRACAnalysis® Rearrangement Test [BART]) III-DIA.04
Maternal Plasma Testing for Detection of Cell-Free Fetal DNA for Analysis of Chromosomal Aneuploidies (revised to reflect use of MCG Care Guidelines®) III-DIA.11
Medicaid Home Care Nursing (HCN) Services (formerly Medicaid Private Duty Nursing (PDN) Services) III-HOM.05
Medicaid Home Health Aide III-HOM.04
Personal Care Assistance III-HOM.03
Proton Beam Radiation Therapy (revised to reflect use of MCG Care Guidelines) III-MED.06
Skilled Nursing Facility (revised to reflect use of MCG Care Guidelines) III-INP.03
Thoracic Sympathectomy for Primary Hyperhidrosis (revised to reflect use of MCG Care Guidelines) III-SUR.25

Medica clinical guidelines — Revised
These versions replace all previous versions.

Name Guideline number
Management of Benign Uterine Conditions VI-GYN.01
Preventive Services for Children and Adolescents Enrolled in Medica Choice CareSM, Medica AccessAbility Solution® and Medica MinnesotaCare VI-PRV.01

Coverage policies — Revised
These versions replace all previous versions.

Name
Diagnosis and Treatment of Chronic Cerebrospinal vascular Insufficiency (CCVSI) in Multiple Sclerosis (formerly Treatment of Chronic Cerebrospinal vascular Insufficiency (CCVSI) in Multiple Sclerosis)
Genetic Testing for Malignant Melanoma (administrative update)
Outdoor Behavioral Healthcare

These documents will be available online or on hard copy:


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Pharmacy News


Effective January 1, 2016:
Medica to make annual update to Part D drug formularies

Each year, Medica makes changes to its coverage and cost-sharing for Medicare Part D drugs. Effective January 1, 2016, certain drugs will either be removed from the Medica Medicare Part D drug formularies or be subject to a change in preferred or tiered cost-sharing status. The "2016 Part D Formulary Change Notification" will be posted on medica.com as of November 1, 2015, which is 60 days prior to the effective date of this change. Medica will also notify affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly.

Note: There are several Medica Part D formulary changes that providers should be aware of for next year. Most changes will apply to Medica Prime Solution® members with a Part D benefit, but some will apply to Medica DUAL Solution® members, too. Medica has notified its members affected by these changes. These Medicare members will likely need to discuss medication options with their provider. Some key upcoming Part D formulary changes are:

  • Most brand-name drugs with a generic alternative are being removed from formulary, such as Synthroid®, Ativan® and Flonase®.
  • Changes to quantity limits will apply to certain drugs, such as fentanyl patches and Nicotrol® inhalers.
  • New step therapy requirements will apply to certain drugs, such as Crestor®, Pradaxa® and Victoza®.
  • Some drugs will move to a higher tier, such as allopurinol, which is moving from tier 1 to tier 2.
  • Compounded drugs will no longer be covered.
  • Plans will have generally lower generic cost-sharing and deductibles, higher brand cost-sharing, and fixed copays for tiers 1-4.
  • There will be 8 distinct Part D plan designs available to Medicare members, depending on which medical plan they choose.
  • Members who choose a Medica Part D plan to go with their medical coverage will no longer be able to switch medical plans throughout the year.

Providers can refer to a comprehensive list of all previous Medica Medicare Part D drug formulary changes. View Medicare Part D drug formulary changes on medica.com.

The 2016 Medica Medicare Part D drug formularies are available online or on paper:

Medication request forms
A medication 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:

  • Download a coverage determination form at medica.com. 
  • Call MedImpact at 1-800-788-2949.

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Network News


Second-quarter PCR checks to be mailed in October 2015

By the end of October 2015, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the second quarter of 2015. This represents a 100-percent return of the second-quarter 2015 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of April 1, 2015, through June 30, 2015, and dates paid of April 1, 2015, through September 30, 2015.

Note: Medica began processing claims with a 2 percent payment reduction in April 2013 due to federal sequestration legislation. The 2 percent sequester reduction was in addition to the standard PCR withhold amount for Medica Prime Solution claims. This 2 percent cut will not be included in PCR returns.


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Administrative News


ICD-10 codes and retroactive authorization requests

For retroactive authorization and notification requests, in situations where such actions were not previously taken, providers should keep the following principles in mind as they pertain to ICD-10 codes. Generally, the rule is to use ICD-9 diagnosis codes for any dates of service prior to October 1, 2015, and use ICD-10 codes for dates of service on or after October 1, 2015.

Situation Response
Post-authorization (retrospective) cases The ICD diagnosis code version must be differentiated by the service date.
Inpatient cases The ICD diagnosis code versions must be differentiated by the discharge date. If the discharge date is before October 1, 2015, then the code must be an ICD-9 diagnosis code. If the discharge date is on or after October 1, 2015, then the code must be an ICD-10 diagnosis code. Use the expected discharge date if the actual discharge date has not been entered. Otherwise, use the actual discharge date.
Outpatient and outpatient facility cases The ICD diagnosis code version must be differentiated by the service end date. If the service end date is before October 1, 2015, then the code must be an ICD-9 diagnosis code. If the date is on or after October 1, 2015, then the code must be an ICD-10 diagnosis code.

The Centers for Medicare and Medicaid Services (CMS) also made recent clarifications to its “Guidance” on the use of ICD-10 codes. See details.


Effective January 1, 2016:
Medica ready for new provider demographic-update requirement
         CMS requires ‘real time’ provider directories

The Centers for Medicaid and Medicare Services (CMS) recently published rules requiring additional information for Medica’s provider directories as well as regular updates to them. The new rules require, among other things, that provider directories be accurate and updated in “real time.” In order to comply with these new rules, Medica requires that providers update practitioner and site-level demographic data as soon as they know of a change to that data, and to review their demographic information for accuracy at least monthly.

Providers can update practitioner and site data in two ways:

Note: In order to update a demographic change to a practitioner or clinic or other site, the appropriate form must be completed, signed and dated by the individual authorized by the practitioner or provider to make demographic changes on their behalf. Incomplete forms will be returned without processing. Medica has updated its website to reflect the above process. See details.

More details
For more information regarding the demographic update requirements, providers can review:

In addition, CMS has published a proposed rule for updated provider directory requirements for Medicaid programs. Medica may modify provider demographic update requirements and processes as the Medicaid rule is finalized and implemented. Refer to the proposed Medicaid rule (see pages 48-57).


Effective January 1, 2016:
New claim edits to help with electronic billing in real time

Effective with January 1, 2016, dates of service, Medica will launch a new “advanced claim edits” system, which will emphasize correct coding and thereby improve efficiency in claims processing. The edits will include flags for missing or inaccurate claim information prior to submitting a claim, allowing providers to correct claims in real time. As a result, this new process should reduce claim denials, avoid delays for time-consuming claim review, and ultimately speed up payments.

This new process will be available to all provider offices that submit claims electronically to Medica, including those that transmit claims via clearinghouses or billing services. The system should be seamlessly integrated so that providers can use the new advanced claim edits during the normal electronic data interface (EDI) process, as electronic claims are prepared for submission.

Claim-rejection reports will indicate errors so that providers have the opportunity to modify claims on the front end and make sure they have the correct information. Providers can decline the system’s feedback, choosing not to change the claim and resubmitting it in its original format, so it will then move on to the Medica claims-adjudication system for processing.

Medica will continue to publish more information about this claims-editing enhancement in the coming months.


Effective January 1, 2016:
Medica to modify process for claim adjustments and appeals

Medica will soon implement a new process for claim adjustments and appeals. Effective with January 1, 2016, dates of processing, the new process will limit the number of requests Medica will review after a claim has been adjudicated. This limit will include two requests for a claim appeal: an initial request and a final request. Any additional submissions will be viewed as duplicates and denied as provider liability.

To submit a request beginning January 1, 2016, providers should complete the “Claim Adjustment or Appeal Request Form,” then attach supporting documentation and send it to Medica at the appropriate address on the form. The new Claim Adjustment or Appeal Request Form will replace the existing Claim Adjustment Request Form and the Claim Appeal Request Form. These current forms should no longer be used as of January 1, 2016.

For more details on these changes to adjustments and appeals, Medica will soon update the Medica Provider Administrative Manual.


Effective January 1, 2016:
Medica to revise reimbursement policies

Medica will soon update the reimbursement policies indicated below, effective on or after January 1, 2016. Such policies define when specific services are reimbursable based on the reported codes.

Maximum frequency per day (units)
The Maximum Frequency per Day (Units) policy addresses reimbursement for claims submitted with multiple units for the same Current Procedural Terminology (CPT®) code or Healthcare Common Procedure Coding System (HCPCS) code on the same date of service by the same physician or other qualified health care professional. Effective with dates of processing on or after January 1, 2016, Medica will update the claims processing system maximum-frequency-per-day unit values to further align with the Centers for Medicare and Medicaid Services (CMS).

  • The CMS Medically Unlikely Edit program was developed to reduce the paid claims error rate for Medicare claims. Unit limits are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, CPT and HCPCS code descriptors, CPT coding instructions, nature of a service or procedure, nature of equipment, and unlikely clinical treatment.
  • Providers may continue to submit appeals with documentation for units denied over the daily limits. However, claim denials based on unit assignment will not be overturned when units of service on the same date of service would be considered impossible because of the code description or other coding or billing instruction.

Multiple procedure reduction
Medica will update the Multiple Procedure Reduction policy to further align with the Centers for Medicare and Medicaid Services (CMS) and apply the special rules for multiple endoscopy reduction. Medica currently applies the standard multiple procedure payment reduction of 50 percent to all secondary and subsequent codes with a multiple procedure indicator of 2 or 3 in the CMS National Physician Fee Schedule (NPFS). Effective with dates of service on or after January 1, 2016, the special rules for endoscopic payment reductions will be applied for multiple endoscopic procedures performed on the same day by the same individual provider. Refer to the NPFS from CMS.

Multiple endoscopic procedures subject to reduction are identified in the NPFS with a multiple procedure indicator of 3: Special rules for multiple endoscopic procedures apply if a procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).

Endoscopy “families” were created by CMS and are a set of codes that consist of a single base code (endobase) and other endoscopy codes; each group or “family” of codes shares the same endoscopic base procedure. There are currently 33 unique codes in the endobase code field in the NPFS. The CMS Total Non-Facility or Total Facility Relative Value Units (RVU) is used to determine the ranking of primary, secondary and subsequent multiple endoscopic procedures:

  • Services with the highest RVU will be considered primary and services with the lower RVU will be considered secondary and subsequent.
  • The endoscopy procedure with the highest RVU will be reimbursed at 100 percent of the allowable amount.
  • The secondary and subsequent endoscopies of the same family will be reimbursed the difference between the allowable amount of the secondary procedure code and the allowable amount of the endoscopic base code.
  • When multiple endoscopy codes are billed on the same day as other surgical procedures, endoscopy codes may be subject to both endoscopic and multiple surgery reductions.

These revised policies will be available online or on hard copy:

  • View Medica’s reimbursement policies as of January 1, 2016; 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.

Effective January 1, 2016:
Medica to implement new reimbursement policy

Medica will soon implement the new reimbursement policy indicated below, effective with dates of service on or after January 1, 2016. Such policies define when specific services are reimbursable based on the reported codes.

Multiple procedure payment reduction for diagnostic imaging
Medica will align with the Centers for Medicare and Medicaid Services (CMS) and implement the new policy, “Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging.” Diagnostic imaging services subject to reduction are services identified in the CMS National Physician Fee Schedule (NPFS) with a multiple procedure indicator of 4. Refer to the NPFS from CMS.

For the technical component of multiple procedure indicator 4 codes (represented by modifier TC), and to the technical portion of global diagnostic imaging services, payment will be made at:

  • 100 percent of the allowable amount for the technical component service ranked as primary
  • 50 percent for second and subsequent technical component services furnished by the same physician or another physician from the same group (same federal tax identification number, or TIN) on the same day

For the professional component of multiple procedure indicator 4 codes (represented by modifier 26), and to the professional portion of global diagnostic imaging service(s), payment will be made at:

  • 100 percent of the allowable amount for the professional component service ranked as primary
  • 75 percent for second and subsequent professional component services furnished by the same physician or another physician from the same group (same federal TIN) on the same day

Multiple procedure payment reductions apply separately to the technical and professional components 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.

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:


Effective January 1, 2016:
Medica to update claim processing system for consistency

Medica will update its claim processing system to achieve consistency with claim edits related to the following reimbursement policy, to be effective with dates of processing on or after January 1, 2016. Such policies define when specific services are reimbursable based on the reported codes. This system change will ensure that claim edits are applied appropriately. It is not a change to a policy, but simply an update to system edits.

Bilateral procedures
Bilateral services are procedures that can be performed on both sides of the body during the same session or on the same day by the same physician or other qualified health care professional.

  • According to the Centers for Medicare and Medicaid Services (CMS) definition, codes with a bilateral status indicator of “1” are subject to a payment adjustment for bilateral procedures. When billed with the modifier 50, they will be reimbursed at 150 percent of the fee schedule amount for the single code.
  • According to the CMS definition, codes with a bilateral status indicator of “3” indicate the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or is reported for both sides with modifiers RT and LT, it will be reimbursed at 100 percent of the fee schedule amount for each side.

The Bilateral Procedures policy is available online or on hard copy:


Updates to Medica Provider Administrative Manual

To ensure that providers receive information in a timely manner, changes are often announced in Medica Connections that are not yet reflected in the Medica Provider Administrative Manual. Every effort is made to keep the manual as current as possible. The table below highlights updated information and when the updates were (or will be) posted online in the Medica Provider Administrative Manual.

Information updated Location in manual When posted online in manual
To comply with applicable state and federal regulations for Medicare and Medicaid:
  • Added definition of “Medical Necessity”
  • Providers are allowed up to 12 months from date of service to submit claims for Medicare and Medicaid
“Special Contracting Requirements" section, in "Government Program Requirements" subsection, under "Provider Requirements for Medicare, Medicaid and Government Programs” September 2015 (effective 9/15/15)

For the current version, providers may view the Medica Provider Administrative Manual online.


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PPO News


Latest UHC provider bulletin available online

UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (September 2015). Highlights that may be of interest to LaborCare® network providers include:

  • Certain outpatient surgical procedures in an outpatient hospital setting require prior authorization — now effective
  • Administering inflammatory medications in hospital outpatient facilities requires prior authorization — now effective
  • To procure Synagis during 2015-2016 respiratory syncytial virus (RSV) season, same process as last year applies, using enrollment form on UHC website

View the September 2015 UHC provider bulletin »


New UHC tool to assist LaborCare, Wis. SelectCare providers

UnitedHealthcare has developed a new digital online tool called “Link.” This new resource may be helpful for both LaborCare® network providers and Medica SelectCareSM providers in western Wisconsin who see UnitedHealthcare Medicaid members.

Link provides a quicker, easier way to do several administrative functions: check member benefits and eligibility, determine claim status, submit claim reconsiderations, update provider demographics, submit referrals, and more. The Link dashboard of applications can help providers get to the information they need with fewer clicks, providing “an intuitive self-service experience.” See more details at unitedhealthcareonline.com.


Latest Aetna provider bulletin available online

Aetna has published its latest edition of Aetna OfficeLink UpdatesTM (September 2015). Highlights that may be of interest for SelectCare network providers include:

  • Hip surgery to require precertification — scheduled for January 2016
  • Submitting appropriate codes for preventive care
  • Members with contraceptive benefits receive new ID cards
  • Aetna utilization management (UM) decisions based on evidence-based clinical guidelines

View the September 2015 Aetna provider bulletin »


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Posted: October 14, 2015


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