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Provider Medica Connections



December 2015

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

General News

Effective January 1, 2016:
Medica offers new Altru IFB product in N. Dakota, Minnesota

Effective January 1, 2016, Altru Health System and Medica are offering a new product for Medica individual and family business (IFB) members. “Altru Prime by MedicaSM” includes a large localized network of health care in northwest Minnesota and northeast North Dakota, with more than 30 primary and specialty clinics and 13 hospitals.

This new IFB product will be available both on and off the federal Marketplace exchanges in these two states. Plan design options will 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.

For more details about this product, see the Altru Prime fact sheet.

Use of concurrent review, prior authorization expanding
         Will apply to certain types of facilities

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

Also 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. Medica will review these services prior to admission, concurrently or retrospectively to determine if medical necessity criteria were met. As a result, if facilities have not met medical criteria, 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 to update radiology cost information for consumers

Medica will soon update the cost information for imaging services on its Main Street Medica website for consumers. This update will occur in February 2016.

For nine years, Medica has been making pricing information available to its members online. As part of the update process, Medica conducts a review of recent claims to determine the conditions, diseases and procedures to be included. These services are then analyzed to determine the cost information based on current contracts for the Medica Choice® Passport provider network. The results will continue to be displayed for organizations using average cost ranges for a particular supply, condition, disease or procedure.

Providers who have any questions about the information on Main Street Medica, or would like to receive a copy of a report for their organization, are welcome to contact their contract manager.

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Clinical News

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

The following benefit determination will be effective beginning with January 1, 2016, dates of service. This new policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.

Vestibular evoked myogenic potentials testing
Medica has reviewed vestibular evoked myogenic potentials (VEMP) testing and has determined that it is investigative and therefore will not be covered.

VEMP testing, also known as click evoked neurogenic vestibular potential testing, is used to ascertain whether vestibular organs and associated nerves are functioning normally. The vestibular organs are stimulated with sound, which activates muscle responses, and results are recorded. VEMP testing is noninvasive and utilizes skin surface electrodes and earphones. This testing has been proposed for use in the diagnosis of benign paroxysmal positional vertigo, Ménière's disease, and some other neurologic disorders.

The complete text of the policy that applies to the determination above will be available online or on hard copy:

  • See Medica’s coverage 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 make coverage policy change

The following benefit determination will be effective beginning with January 1, 2016, dates of service. This change will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.

Laser therapy for treatment of pain
Medica has reviewed high-level (e.g., class IV) laser therapy for treatment of pain and has determined that this technology is investigative and therefore will not be covered. This determination will be incorporated into a new policy titled “Laser Therapy for Treatment of Pain,” replacing the current coverage policy “Low Level Laser Therapy for Treatment of Pain.” Low-level laser therapy for treatment of pain was also determined to be investigative and therefore will continue to not be covered.

Laser therapy for treatment of pain has been purported for use with either low-level lasers or high-power lasers. Low-level laser therapy uses non-thermal, red-beam or near-infrared beams delivered by direct contact with the skin. High-power laser therapy for pain uses hand-held devices providing energy delivered without direct contact with the skin. These devices are not to be confused with class IV surgical lasers. Conditions purportedly responding to this therapy include (but are not limited to) back pain; headache and migraine; temporal mandibular joint (TMJ) dysfunction; carpal tunnel syndrome; arthritis; neuropathy; trigeminal neuralgia; fibromyalgia; and tendinitis.

The complete text of the policy that applies to the determination above will be available online or on hard copy:

Effective January 1, 2016:
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 January 1, 2016, unless otherwise noted.

UM policies — New

Name Policy number
Inpatient Rehabilitation Facility (Acute Rehabilitation) III-INP.05
Long-Term Acute Care Hospital (LTACH) III-INP.04

Coverage policies — New

Vestibular Evoked Myogenic Potentials (VEMP)

Coverage policies — Revised
These versions replace all previous versions.

Birth Centers (Free-Standing)
Bone Morphogenic Protein (BMP) for Spine and Orthopedic Applications
Laboratory Testing
Laser Therapy for Nicotine Dependence (formerly Laser Therapy for Smoking Cessation)
Laser Therapy for Treatment of Pain (formerly Low Level Laser Therapy for Treatment of Pain)
Stem Cell Therapy for Orthopedic Applications (formerly Autologous/Allogeneic Stem Cell Infusion for Orthopedic Applications)

These documents will be available online or on hard copy:

Medica re-organizes listing of coverage policies online

The coverage policies on the Medica website have been reorganized to make it easier for providers to find what they need. These policies are now divided into intuitive categories, with links for policy titles now better reflecting the content of each policy and the most commonly searched terms. The designated categories for Medica’s coverage policies are:

  • Devices/Equipment
  • Diagnostics — General
  • Diagnostics — Laboratory Tests
  • Genetic Tests
  • Imaging
  • Medical Treatments – General
  • Surgical Procedures/Back Treatments
  • Surgical Procedures — General
  • Therapy
  • Wound Therapy

See the new listing of Medica’s coverage policies.

Note: These changes only affect the appearance on the website and do not reflect any change to coverage determinations.

Evaluation and treatment of ADHD for proper care

Attention deficit hyperactivity disorder (ADHD, or ADD) is one of the most common childhood neurodevelopmental disorders and can continue through adolescence and adulthood. Most diagnoses for ADHD are made by the primary care physician. At this time, the causes of ADHD are unknown, but many studies suggest that genes play a major role. Other possible causes are environmental factors such as cigarette smoking and alcohol use during pregnancy, exposure to lead, premature delivery, low birth weight, or traumatic brain injury.

Diagnosing ADHD
Diagnosing the condition can be difficult. The symptoms usually appear in early life, often between 3 and 12 years of age. There is no single test for diagnosing ADHD. To diagnose it in an adult, the symptoms should have begun in childhood and continued throughout adulthood.

The American Academy of Pediatrics recommends that the primary care clinician should initiate and evaluate children for ADHD in any child age 4 to 18 years of age who present with academic or behavioral problems. The diagnosis should determine that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria have been met and information should be obtained primarily from reports by the parent or guardian, teachers, and daycare providers because symptoms occur across domains, whether in school, at home or at work. The providers also need to assess any other conditions that may coexist with ADHD, looking for any chronic conditions that may be involved, and then treat as appropriate for the age of the child or adult.

Providers should be looking for symptoms such as inattention, hyperactivity, and impulsivity. Behaviors include lots of daydreaming, forgetfulness or frequently losing things, talking too much, taking unnecessary risks, carelessness, impulsive behavior, and having difficulty getting along with others. Such symptoms should be present for 6 months and to a degree that is greater than other children of the same age or for adults the behaviors started in childhood. Parents or teachers may report the child is easily distracted and exhibits many of the behaviors mentioned above.

Treating ADHD
ADHD cannot be cured, but can be successfully managed. Currently, available treatments focus on reducing the symptoms of ADHD (impulsivity, inattention, hyperactivity) and improving a patient’s function. Treatment options include medications, psychotherapy, education, and training, or a combination of these. If medications are prescribed, patients should follow up with their providers within 30 days of a medication start. In addition, patients should be seen at least twice for follow-up visits within a 9-month period. It may help to encourage parents or the adults with ADHD to do the following:

  • Keep the same routine every day and keep the schedule written so it can be easily followed. Changes on the schedule should be made as far in advance as possible.
  • Organize everyday items including clothing, toys, books, work papers, etc.
  • Be sure rules are clear and consistent.
  • Praise and reward children when rules are followed.

Children and adults with ADHD can learn to compensate for areas of weakness and start taking advantage of their strengths. Identification of the condition and determining appropriate treatment are important components to properly care for these patients.

Bariatric surgery has varied coverage, multiple requirements

Medica members’ coverage for bariatric surgery varies according to the terms of member coverage documents. This coverage can vary considerably. Members should refer to their plan document to verify their requirements before pursuing bariatric surgery. Members must verify that the facility performing the procedure is part of their plan’s network and is also designated as a Center of Excellence, if required.

Before members receive any services, providers and members are also encouraged to contact Medica by calling the phone number on the back of the member’s ID card to verify benefits and any employer-based requirements. Additional requirements could include not just seeing certain providers but meeting specific medical criteria prior to surgery, as well as having surgery at specific locations in the provider network.

Finally, prior authorization is needed before all bariatric surgeries.

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Network News

Effective January 1, 2016:
Medica to implement commercial, PPO fee schedule updates

Effective January 1, 2016, Medica will implement standard fee schedule updates for commercial products in both its metro and regional service areas. The Medica SelectCareSM and LaborCare® standard fee schedules will be updated at the same time — i.e., for the Medica preferred provider organizations (PPOs).

These updates will result in an overall estimated increase to physician reimbursement. As always, the effect on reimbursement will vary by specialty and the mix of services provided.

Various fees for services without an assigned Centers for Medicare and Medicaid Services (CMS) relative value unit (RVU) will also be updated. Examples of these services include labs, supplies/durable medical equipment (DME), injectable drugs, and immunizations. This non-RVU update will also have an impact on physician reimbursement that will vary based on specialty and mix of services provided.

Medica will apply CMS-based RVU methodology where applicable. The CMS Medicare physician RVU file (National/Carrier) is available online at the CMS website.

Providers who have further questions may contact their Medica contract manager.

Effective January 1, 2016:
Medica to update Medicare physician fee schedule

Beginning with January 1, 2016, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will coincide with the implementation from the Centers for Medicare and Medicaid Services (CMS).

This fee schedule change incorporates CMS relative value units (RVUs) and the conversion factor for year 2016 as well as various Medicare non-RVU fee maximums (such as labs, injections, immunizations, etc.). In addition, Medica will also update its Medicare fee schedule with rates for codes without a fee maximum established. Overall reimbursement for providers will depend on specialty and mix of services provided.

Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.

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Administrative News

New passwords required for Medica secure provider portal

Medica recently enhanced the security of its website. Providers now will periodically be asked to reset their user password in order to access electronic transactions on A new password will be required when there is no activity in provider accounts. This new step was added to better protect provider information and members’ personal health information (PHI) available through Medica’s secure electronic transactions, such as eligibility, claims status inquiry, and payments and statements.

As a result of this new security effort, if there’s been no activity in a user’s account for 90 days, the password for that user’s account will be reset. And if there’s been no activity for 180 days (meaning a user has not accessed electronic transactions for half a year), the user’s account will be disabled. The primary administrator for the provider group would need to re-register the user to enable access to transactions after that point.

Furthermore, if a provider group’s primary administrator hasn’t created a username and password within 180 days of initial registration of a federal tax ID number on, the provider group’s account will be disabled, requiring initial registration again.

New claim edits should speed up claim submission, payments

As a reminder, Medica will launch a new claims-editing enhancement that will emphasize correct coding and improve efficiency in claims processing. This should reduce claim denials, avoid delays for time-consuming claim review, and ultimately speed up payments. This new “advanced claim edits” system will be effective with January 1, 2016, dates of service.

The new claim edits will include flags for missing or inaccurate claim information prior to submitting a claim, allowing providers to correct claims in real time. Providers need to review claims acknowledgement reports (277CA reports) received from their clearinghouse and take appropriate action. This extra step should help ensure that providers submit claims accurately and effectively. However, claim delays or denials can still result if providers choose to forgo suggested claim edits.

(Update to "New claim edits to help with electronic billing in real time" article in the November 2015 edition of Medica Connections.)

Effective January 1, 2016:
After delay, advanced-practice specialty types to change

Effective January 1, 2016, Medica will make a system update related to the following advanced-practice practitioners: certified nurse practitioners, certified nurse-midwives, and physician's assistants.

This update, delayed from last year, will better align these practitioners with the specialty services they perform at their respective clinics. These advanced-practice practitioners will now have their individual specialty type designated in the Medica credentialing and claims databases. Medica credentialing requirements will also reflect new regulatory requirements that pertain to supervising physician oversight of nurse practitioners and midwives. Medica will no longer validate supervising physician information as it is a requirement for licensure.

This upcoming system update may have an impact on the way these advanced-practice providers are displayed in directories and on provider reimbursement rates. It would also affect Medica member benefits to better align them with the specialty services being performed by advanced-practice practitioners in accordance with their Medica provider contracts.

(Update to “Medica postpones change to mid-level provider specialty types" article in the February 2015 edition of Medica Connections.)

Effective January 1, 2016:
Medica to revise reimbursement policy

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

Reimbursement policies — Revised
These versions replace all previous versions.

Place of Service (POS) Reference Guide (updated code list)

This revised policy will be available online or on hard copy:

Time frame updated in facility-admission reimbursement policy

The Services Incidental to Admission facility reimbursement policy has been updated to clarify the time frame in which outpatient services prior to inpatient admission will be considered incidental. The policy now states that all services provided by the hospital on the date of the inpatient admission or immediately preceding the admission will be considered incidental to admission. This policy change is more in alignment with Centers for Medicare and Medicaid Services (CMS) reimbursement for Medicare members.

To view the policy in its entirety, refer to the Services Incidental to Admission policy. This revised policy is available online or on hard copy:

Requirements for inpatient hospital interim billing

Medica has adopted inpatient hospital interim billing requirements, which were published in the April 2014 edition of Medica Connections. These requirements, effective with May 1, 2014, dates of service, were outlined in the Medica Provider Administrative Manual. They are as follows:

Medica will allow interim billing for inpatient hospitalizations spanning more than 30 days.

  • Claims are to be billed in at least 30-day intervals or upon discharge.
  • Each claim (first, continuing, and last) must include a comprehensive list of all diagnoses and procedures — even if included on the previous claim.
  • Interim bills must be submitted in the same sequence in which the services were provided using the correct type of bill sequence (0112, 0113, 0114).

In addition, the UB-04 data elements necessary to correctly bill interim claims are included in the Medica Provider Administrative Manual. Refer to the Claim Submission Requirements for Facilities section of the manual — “Inpatient Hospital Interim Billing” information is located under the “Submission Info” section.

CMS requires providers to regularly update demographic data

As published last month, Centers for Medicaid and Medicare Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them, effective January 1, 2016. The new rules state, among other things, that provider directories be accurate and updated in “real time.” As a result, providers need to update their practitioner and site-level demographic data in Medica’s directories as soon as they know of a change to that data, and to regularly review their demographic information for accuracy. See more details.

Effective February 1, 2016:
Medica to add new provider specialty designation

Effective February 1, 2016, Medica will add a new practitioner specialty to identify practitioners as part of their provider demographics (for instance, available in provider directories for Medica members to use). The new specialty is Palliative Care. Practitioners with the appropriate training or education who would like to request Palliative Care as their specialty can do one of the following:

  • If already credentialed with Medica, submit a Minnesota Uniform Practitioner Change Form to Medica.
  • If new to the Medica network, submit an initial credentialing application using ApplySmart or send the application by e-mail to Medica.

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
Added language noting that adjustments for coordination of benefits, subrogation, duplicate payments or retroactive terminations due to retroactive eligibility for a government program or subsidy can be made at any time "Administrative Policies and Procedures" section, in "Adjustment Guidelines" subsection (under “Adjustment Time Frames") November 2015
(effective 12/31/15)
Updated language to clarify that a longer time frame may be required for claims submission “Billing and Reimbursement” section, in “Claim Submission Requirements for Facilities” and “Claim Submission Requirements for Professional Services” subsections November 2015
(effective 12/31/15)
Updated references within the "Commercial Fee Schedule Update Policy" "Billing and Reimbursement" section, in "Commercial Fee Schedule Update Policy" subsection November 2015
(effective 1/1/16)
Added details outlining new adjustment and appeals process for providers, with new limit of 1 adjustment and 1 appeal “Administrative Policies and Procedures” section, in “Adjustment Guidelines” subsection November 2015
(effective 1/1/16)

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 (October 2015). Highlights that may be of interest to LaborCare® network providers include:

  • Prior authorization for infertility services — now effective
  • ICD-10 diagnosis codes for skilled nursing services — now effective
  • Genetic counseling required for prior authorization — scheduled for January 2016

View the October 2015 UHC provider bulletin »

MHCP applications may delay payment of DOC inpatient claims
         Centurion has 90-day wait period before paying such claims

All Minnesota Department of Corrections (DOC) inpatient claims should be submitted for Minnesota Health Care Programs (MHCP) payment first, unless the inmate is not eligible. In cases where the inmate has an MHCP application in process, Centurion cannot pay inpatient claims and is required to deny for other coverage. Even in cases where Centurion ends up paying claims, it is only after the DOC has exhausted attempts to get the inmate to sign an application for coverage and 90 days have elapsed.

As a reminder, a person incarcerated in a state or local correctional facility may qualify for Medical Assistance payments for inpatient hospital services. As a result, for health care services provided to Minnesota DOC prisoners, Medica SelectCareSM network providers should verify whether or not the patients are enrolled in MHCP before submitting inpatient claims to Centurion of Minnesota, LLC. Centurion was selected by the State of Minnesota to manage the medical needs of offenders at Minnesota DOC prisons.

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Posted: November 11, 2015

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