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Provider Medica Connections


March 2016

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

General News

Medica Foundation announces provider grant recipients
        Second-round 2015 program grants awarded, totaling $500,000

The Medica Foundation has concluded its second round of grant-making in 2015, awarding program grants totaling $500,000 to 51 nonprofit organizations. Grants were awarded to several provider groups:

  • A Chance to Grow (Minneapolis) — to expand the Mobile Vision program with Head Start centers in Hennepin and Ramsey counties to provide eye exams, glasses and vision care
  • Children’s Dental Services (Minneapolis) — to implement an innovative medical/dental services integration project to serve low-income children in Hennepin County
  • Family Healthcare Center (Fargo, N.D.) — to support the work of the clinic in providing primary health care programs including medical, dental and behavioral health services
  • The Family Partnership (Minneapolis) — to provide therapy groups in classrooms for low-income preschoolers and enhance parental nurturing and behavior management
  • Knute Nelson Foundation (Alexandria, Minn.) — to deliver health care services that help seniors live independently
  • Lutheran Social Service of Minnesota (Duluth, Minn.) — to support the Teen Clinic that provides drop-in medical care for low-income, at-risk and homeless youth
  • Lutheran Social Service of Minnesota (St. Cloud, Minn.) — to support the St. Cloud Area Crisis Nursery to provide emergency childcare placements and a 24-hour crisis phone line
  • St. David’s Center for Child and Family Development (Minnetonka, Minn.) — to expand mental health services into agencies in Carver County and the Robbinsdale area
  • Washburn Center for Children (Minneapolis) — to provide additional mental health interventions to help young children develop social, emotional and behavioral skills
  • Women’s Health Center of Duluth (Duluth) — to provide medical and preventive health services in northeastern Minnesota

This cycle of grant-making provided funds to support early intervention programs that focus on healthy families to foster the optimal growth and development of young children. In addition, funding was provided to organizations in the regional and rural areas of Medica’s service area to support health-related programming that is core to each organization’s nonprofit mission.

In total for 2015, the Medica Foundation awarded 104 grants totaling $1,494,500 to 98 nonprofit and government agencies. Details about 2016 funding opportunities are available online at

Due by April 15, 2016:
Practices encouraged to validate their demographic data

Each year, providers are asked to review and validate the information Medica has about their practice sites. While providers are also now required to submit data changes to Medica as they occur throughout the year, this annual data-validation project allows providers to verify the accuracy of their information currently listed in the Medica database, applicable for all Medica products.

This year, Medica plans to send providers demographic-update notifications by e-mail in late March 2016. Responses will be due by April 15, 2016. Instructions and electronic links are provided for verifying data and making changes using the Medica secure Provider Demographic-update Online Tool (PDOT) found on Providers who do not receive this annual notice by e-mail will receive a postcard directing them how to register on and access PDOT.

It is helpful for providers to respond by the deadline each year. Timely responses ensure that Medica has accurate information in its systems, which is essential for prompt and accurate claims payment as well as displaying current information in printed and online provider directories. Up-to-date demographic data helps to ensure efficient claims adjudication, reduce re-work and increase patient satisfaction.

Medica would like to extend a sincere thank-you to provider groups for taking the time to help keep their records up-to-date.

Providers need to return ‘Disclosure of Ownership’ forms

As published last month, providers should complete and return a Disclosure of Ownership Statement no later than March 1, 2016 (if they have not yet done so). This disclosure form can be returned to Medica by e-mail.

Providers who see patients covered under Medica products for government programs need to complete the Disclosure of Ownership Statement and return it to Medica each year. This step is necessary for Medica to comply with contracts it holds with both the Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Human Services (DHS). Learn more about this requirement.

Medica covers patient education by community health workers

As a reminder, Medica’s Minnesota Health Care Programs (MHCP) enrollees are eligible to receive patient education services provided by a certified community health worker. This applies to Medica members in Medica MinnesotaCare, Medica DUAL Solution®, Medica Choice CareSM (including those in Minnesota Senior Care and Minnesota Senior Care Plus state programs), and Medica AccessAbility Solution® products.

Medica covers diagnosis-related patient education services, including diabetes prevention and pediatric obesity treatment provided by certified community health workers who have also been enrolled as such by the Minnesota Department of Human Services (DHS). Medica will cover these services when the following criteria have been met:

  • The community health worker is supervised by a network physician, participating advanced practice registered nurse (APRN), certified public health nurse, dentist or mental health professional.
  • A physician, APRN, dentist, certified public health nurse or mental health professional must order the patient education services and must order that they be provided by a community health worker.
  • The service involves teaching the patient how to effectively self-manage their health or oral health effectively in conjunction with the health care team.
  • The service is provided face-to-face with the member (individually or in a group) in an outpatient, home clinic setting or other community setting.
  • The content of the educational and training program is a standardized curriculum consistent with established or recognized health or dental health care standards. This curriculum may be modified as necessary for clinical needs, cultural norms, and health or dental literacy of individual patients.

Oral interpretation and sign language services are allowed when requirements are met. For coverage requirements, providers may refer to the MHCP Provider Manual from DHS.

Services should be billed under the supervising physician, APRN, dentist, certified public health nurse agency or mental health professional using the appropriate provider number and national provider identifier (NPI) number. Medica will accept the following procedure codes:

98960 Self-management education & training, face-to-face, 1 patient
98961 Self-management education & training, face-to-face, 2-4 patients
98962 Self-management education & training, face-to-face, 5-8 patients

Providers should bill Medica in the following manner:

  • Use 30-minute units with a limit of four units per 24 hours, and no more than eight units per calendar month per recipient;
  • Use separate lines for each day services are provided; and
  • Include a diagnosis code.

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Clinical News

Colonoscopies still preferred for CRC screening
        Cologuard not recommended by task force, not Medica-covered

Medica believes that colonoscopies continue to be the gold standard for colorectal cancer (CRC) screening. Although many providers want to use Cologuard for colorectal cancer screening, Medica is not approving Cologuard as appropriate testing for colorectal cancer screening. This is for two reasons: at this time, the U.S. Preventive Services Task Force (USPSTF) does not recommend the use of this test; and the National Committee for Quality Assurance (NCQA) will not accept it as part of the Healthcare Effectiveness Data and Information Set (HEDIS®) for colorectal cancer screening.

Medica follows the guidelines set out by USPSTF, which currently are for patients to have:

  • a colonoscopy every 10 years, or
  • a flexible sigmoidoscopy test every 5 years, or
  • a fecal immunochemical test (FIT) every year, or
  • a fecal occult blood test (FOBT) annually.

Furthermore, Medica health plans are accredited by NCQA, which also follows USPSTF guidelines.

Colorectal cancer is the second-leading cause of cancer deaths in the United States. The USPSTF states that in 2015, there were 133,000 people diagnosed with colorectal cancer and about 50,000 people died of the disease. The most frequent victims of this disease are 65-74 years of age, with a median age of death of 73 years. Unfortunately, only about one-third of adults 50-75 years of age are currently screened.

Medica wants all members who are 50-75 years of age to be screened. Medica was the first health plan in Minnesota to sign the “80X18” initiative with the American Cancer Society. The goal of this initiative is to have 80 percent of people living in Minnesota who are within the risk ages to get screened for colorectal cancer by the year 2018.

For patients reluctant to have colonoscopy testing, Medica encourages providers to use the FOBT or FIT. Some tips for these alternative tests are:

  • Never use an in-office FOBT/FIT at the time of a digital rectal exam.
  • Perform a test only on stool specimens collected by patients at their home.
  • Bill the FIT with Current Procedural Terminology (CPT®) code 82274.
  • Bill the FOBT with CPT code 82270.
  • Tests should be billed on the day the test was performed by the lab and not on the day when the test kit was dispensed to the patient for home testing.
  • Patients need to repeat these tests annually.

See more details from the USPSTF or from NCQA.

Effective May 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 May 1, 2016, unless otherwise noted.

UM policies — Revised
These versions replace all previous versions.

Name Policy number
Implantable Deep Brain Stimulation (revised to reflect use of MCG® Care Guidelines) III-DEV.19

Coverage policies — Revised
These versions replace all previous versions.

Autologous Blood-Derived Products for Chronic Non-Healing Wounds
Endoscopic Radiofrequency Ablation for Barrett’s Esophagus
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (formerly Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease [LINX Reflux Management System])
Percutaneous Radiofrequency and Laser Ablation/Denervation Procedures for Facet and Sacroiliac Joints
Quantitative Sensory Tests
Single Photon Emission Computed Tomography (SPECT) for Attention Deficit Hyperactivity Disorder (ADHD)
Upright Magnetic Resonance Imaging (MRI)

Coverage policies — Inactivated

Transobturator Tape (TOT) Sling Treatment for Female Stress Urinary Incontinence

These documents will be available online or on hard copy:

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Pharmacy News

Effective May 1, 2016:
Upcoming changes to Medica Part D drug formularies

Medica posts changes to its Part D drug formularies on 60 days prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective May 1, 2016. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. As of March 1, 2016, view the latest Medicare Part D drug formulary changes.

Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The 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 Medica coverage determination form.
  • Call MedImpact at 1-800-788-2949.

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Administrative News

Effective January 1, 2016:
Medica revises reimbursement policy

Medica has updated 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.

Self-Administered Drugs (updated code list)

This revised policy is available online or on hard copy:

Effective May 21, 2016:
Medica to revise reimbursement policy

Medica will update the reimbursement policy indicated below, effective with May 21, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.

Medica will revise the Supply policy to further align with the Centers for Medicare and Medicaid Services (CMS) by adding non-facility places of service where supplies will not be separately reimbursed.

Per CMS, services performed in non-facility places of service are paid at non-facility rates and are incorporated into the Practice Expense Relative Value Unit (PE RVU) for evaluation and management (E/M) services and/or procedures reported on the same day in a physician or other health care professional’s office. The current Supply policy includes places of service 03, 11, 49, 71 and 72. The following non-facility place-of-service codes will be added to this policy: 01, 04, 09, 12, 13, 14, 15, 16, 17, 20, 33, 50, 54, 55, 57, 60, 62, 65, 81 and 99. If supplies billed for use in any of these places of service are included on the Supply Policy Nonreimbursable Code List, they will not be eligible for reimbursement. This applies to claims billed on a CMS-1500 claim form or its electronic equivalent. See definitions for place-of-service codes from CMS.

Note: Durable medical equipment and home health providers will be excluded from this policy enhancement.

This revised policy will be 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
Updated code list within the Commercial Fee Schedule Update Policy (due to CMS changes to physician fee schedule) “Billing and Reimbursement" section, in "Commercial Fee Schedule Update Policy" subsection February 2016 (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 (February 2016). Highlights that may be of interest to LaborCare® network providers include:

  • New H.pylori serology testing — now effective
  • New codes for advance notification and prior authorization — required for use by March 2016
  • Bilateral Procedures Policy to be revised — scheduled for second quarter 2016
  • Prior authorization to be required for functional endoscopic sinus surgery — scheduled for May 2016

View the February 2016 UHC provider bulletin.

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Posted: February 24, 2016

Date: 9/27/2021 8:30:27 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02