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Provider Medica Connections


June 2016

General News | Clinical News | Pharmacy News | Administrative News | SelectCare/LaborCare News

General News

Effective July 1, 2016:
Medica launches new ACO product with Altru

Medica and Altru Health System recently announced a new product that will be available beginning July 1, 2016. “Altru & You with Medica” is an accountable care organization (ACO) product that will be available in northeastern North Dakota and northwestern Minnesota. Medica and Altru Health System are collaborating to improve the quality of care, reduce the total cost of care and optimize the consumer experience. The new ACO plan option will be available through My Plan by MedicaSM or alongside a Medica Choice® Passport plan.

Altru & You with Medica will give Medica members access to care in more than 30 communities through a network of more than 560 providers, plus regional access using telemedicine. The provider network includes 70 clinics and 17 hospitals in the Altru service area. Altru Health System itself is a community-owned, integrated system with an acute-care hospital, a specialty hospital and a large home care network.

This new ACO product offering will have the following features:

  • access to Altru Advanced Orthopedics for comprehensive, personalized care for bones, joints and concussions
  • care options through e-visits and telemedicine
  • discounted access to Altru’s Weight Management Program: a team of medical providers, dietitians and exercise specialists who can help patients lose weight
  • discounted sessions with certified health and wellness coaches

View the fact sheet for Altru & You with Medica. 

Drs. Benjamin, Braddock join Medica as new medical directors

Two new medical directors are joining the Health Management team at Medica: Barb Benjamin, MD, and Mary Braddock, MD.

Dr. Barb Benjamin has joined Medica as a medical director for Health Management, primarily supporting Medica commercial markets and clinical provider-engagement initiatives, including accountable care organization (ACO) products.

Most recently, Dr. Benjamin was vice president of medical practice at Fairview Medical Group. She has also served as chair of the department of family medicine at Park Nicollet Health Services as well as on the board of directors for Park Nicollet. Board-certified in family medicine, Dr. Benjamin completed her residency at the University of Minnesota hospitals and received her medical degree from the University of Minnesota.

Dr. Mary Braddock will also soon join Medica as a medical director for Health Management. She will primarily support Medica's state programs segment and quality improvement initiatives.

Prior to joining Medica, Dr. Braddock was medical director for national accounts at Optum. Before that, she was associate medical director at Gillette Children's Specialty Healthcare. She also has served as senior director for child health policy advocacy and policy at Children's Hospitals and Clinics of Minnesota. Board-certified in pediatrics, Dr. Braddock received her master's degree in public health from Johns Hopkins University, completed her residency at the University of Texas in Galveston and received her medical degree from the University of Missouri at Columbia.

Both new medical directors report to James Hartert, MD, vice president and senior medical director for health management at Medica. "Both Barb and Mary bring keen insight into health management through their experiences with care delivery as well as key leadership roles at other organizations," said Dr. Hartert. "In their new roles, they will be crucial in aligning our clinical direction with strategic goals for each of our lines of business, ensuring that health care remains affordable while also of the highest quality for Medica';s members."

Personalized member programs help manage chronic conditions

Medica continues to offer support to its members with chronic health conditions. Recently, Medica launched an enhanced condition management program, called “Medica Health SupportSM,” to help eligible members in commercial and Minnesota Health Care Programs (MHCP) plans. The new program represents a transition from a former coaching model to a more targeted, specialized clinical approach for certain conditions.

Through Medica Health Support, the focus now is on three chronic care conditions: asthma (pediatric and adult), diabetes (adult only), and cardiac care (adult only). Using member claims data to identify those who might benefit from the program, Medica initiates member outreach and then works with ActiveHealth Management, which helps administer the program, to facilitate the appropriate level of support. As part of the program, there are options for:

  • telephonic discussions with a registered nurse
  • online condition-specific education, tools and information
  • educational materials that can be mailed to members
  • other resources from the member’s care system, when available

For further information about these services and how to use them, providers may contact Medica at

Individual and family business (IFB) health plan members with one or more chronic conditions may continue to receive support through other no-cost condition management services. A registered nurse is available to work with the member to complete an assessment, to develop personal health goals, and to provide support and follow-up. Members are identified to participate in this voluntary program using claims data as well as referrals. For further information about these services and how to use them, providers may call Medica at 1-855-235-0511, option 3.

As with all health improvement and support programs at Medica, the goal is to provide a personalized, highly relevant experience for each member. With its condition management programs, Medica is focused on offering support that helps individuals manage their chronic conditions. 

Learn more about these and other health improvement programs Medica offers.

Premium Designation current program year winds down
        Remaining reconsideration requests due by July 15

The current program year for the Medica Premium Designation Program will soon come to a close, and preparations for the next program-year rollout in 2017 will be underway. The final deadline for physicians to review their current-year Premium Designation data and to make any final reconsideration requests will be July 15, 2016. Medica will evaluate and respond to reconsideration requests within 30 days. After July 15, 2016, reconsideration requests will not be accepted until the next reconsideration period expected in February 2017. However, Premium Designation reports will still be available for physicians to view until then.

To submit reconsideration requests using the secure program login, or simply for more program details, refer to the Premium Designation home page.

Providers who have questions about Premium Designation may:

Annual notice:
Provider appeals on behalf of Medica members

Medica members have the right to appoint representatives, such as their providers, to initiate member appeals. For cases involving member liability, providers may initiate an appeal on behalf of a Medica member by calling the Medica Provider Service Center. At the request of the member or provider, the appeals staff will conduct a case review of previously denied services to ensure accurate review, and coverage of eligible services according to the member's benefit document. 

For more details about appeals:

  • See Benefit Appeals in the Provider Administrative Manual. 
  • See Member Assistance Services in the Provider Administrative Manual.

Annual notice:
Member rights and responsibilities, for providers to know

Medica recognizes the importance of a three-way relationship among members, their providers and their health plan. Medica believes that educating members about their healthcare responsibilities is important because it helps members get the greatest benefit from their health plan. Medica outlines member rights and responsibilities for the Medica physician and provider community in order to improve the health of the members Medica serves.

As a reminder, information about member rights and responsibilities is posted online. Providers are encouraged to review and understand these details. View Regulatory/Reporting Information in the Medica Provider Administrative Manual.

Annual notice:
Medica reaffirms its policy regarding utilization management

Utilization Management (UM) is a process Medica uses to evaluate healthcare services for appropriateness and efficacy. Medica UM decisions are based on national and local standards that support the provision of evidence-based care. All decisions also incorporate a member's benefits and Medica coverage policies. Medica does not specifically reward providers, practitioners, staff members or their supervisors who conduct utilization reviews on the behalf of Medica for issuing denials of coverage or service. It is important to note that UM decision-makers do not receive financial incentives from Medica as a means of encouraging them to make decisions that result in the underutilization of services.

Providers who want more information about the UM process may refer to Medica UM policies at

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Clinical News

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

The following benefit determination will be effective beginning with August 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.

Powered robotic lower-limb exoskeleton devices
Medica recently reviewed powered robotic lower-limb exoskeleton devices (e.g., ReWalkTM and Indego®) and determined that these devices are investigative and therefore will not be covered.

Powered exoskeleton orthotics devices, also known as lower extremity orthoses, are orthotic devices being developed with the intent of assisting individuals with spinal cord injuries and other lower-limb impairments to ambulate. These wearable, computer controlled devices are equipped with joints that correspond to those of the human body. They are primarily being used in rehabilitation centers, but are emerging for community use to permit individuals with paraplegia to stand and walk in the home setting.

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 August 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 August 1, 2016:
Medica to make UM policy changes

Medica will soon revise the following utilization management (UM) policies that require prior authorization, effective beginning with August 1, 2016, dates of service. These changes will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.

Blepharoplasty, blepharoptosis repair and brow lift
Medica has reviewed blepharoplasty, blepharoptosis repair and brow lift procedures and has made several changes to the medical necessity criteria. Blepharoplasty will require visual field testing (taped and untaped eyelids) to measure visual impairment. In addition, interpretation of the visual field testing must be included in the written documentation submitted with the prior authorization request. Blepharoptosis repair will require marginal reflex distance (MRD) as a solo measurement of visual impairment. Lastly, to determine medical necessity for brow lift, photographs must show the position of the brow at the level of the top of the eyelashes and there must be documentation that the visual impairment cannot be corrected by blepharoplasty alone.

Blepharoplasty, blepharoptosis repair and brow lifts are surgical procedures that may be performed to correct visual impairment, but may also be done for cosmetic purposes to improve appearance. Services not medically necessary, or cosmetic, will not be covered.

Medica has reviewed abdominoplasty/panniculectomy and has made a change to the medical necessity criteria for abdominoplasty. Abdominoplasty is no longer considered medically necessary for rectus diastasis repair, as this is a cosmetic procedure. All remaining indications for abdominoplasty (e.g., to improve surgical access, to optimize post-operative wound healing) continue to be subject to prior authorization. Services not medically necessary, or cosmetic, will not be covered.

Abdominoplasty is a surgical procedure to tighten a lax anterior abdominal wall and involves resection of abdominal skin and fat. The procedure may involve tightening of the abdominal wall through placement of sutures.

The complete text of the policies that apply to the determinations above will be available online or on hard copy:

  • See Medica’s UM policies as of August 1, 2016; or
  • Call the Medica Provider Literature Request Line for printed copies of documents.

Effective August 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 August 1, 2016, unless otherwise noted.

UM policies — Revised
These versions will replace all previous versions.

Name Policy number
Abdominoplasty/Panniculectomy III-SUR.13
Bariatric Surgery III-SUR.30
Blepharoplasty, Blepharoptosis Repair and Brow Lift (formerly Reconstructive Blepharoplasty (Upper or Lower Eyelid), Blepharoptosis Repair (Upper Eyelid) and Brow Lift) III-SUR.29
Bone Growth Stimulators III-DEV.07
Comparative Genomic Hybridization (CGH) Microarray Testing III-DIA.09
Genetic Testing for Cardiac Channelopathies III-DIA.05
Genetic Testing for Cardiomyopathies III-DIA.07
Human Leukocyte Antigen-DQ (HLA-DQ) Genetic Testing for Diagnosis of Celiac Disease III-DIA.08
Mechanical Circulatory Support Devices III-SUR.38
Microprocessor Controlled Knee Prostheses, with or without Polycentric, Three-Dimensional Endoskeletal Hip Joint System III-DEV.17
Outpatient Enteral Nutrition Therapy III-MED.03
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) III-DIA.08

Coverage policies — New

Powered Robotic Lower-Limb Exoskeleton Devices

Coverage policies — Revised
These versions will replace all previous versions.

Bone Morphogenic Protein (BMP) for Spine and Orthopedic Applications
Genetic Testing for Alzheimer Disease
Nasal Expiratory Positive Airway Pressure (Provent®) for Obstructive Sleep Apnea

ICSI guidelines — Revised
These guidelines are available on

Depression in Primary Care (released March 2016)

These documents will be available online or on hard copy:

The importance of regular follow-up for ADHD

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood. Centers for Disease Control and Prevention (CDC) studies suggest that as many as 11 percent of American children 4-17 years of age (numbering 6.4 million) were diagnosed with ADHD just in 2011. ADHD affects children and teens throughout their lives by affecting social skills, school participation, safety and self-esteem.

There are three types of ADHD:

  • Inattention – the child gets distracted easily, has poor concentration and poor organizational skills
  • Impulsivity – the child interrupts, and takes risks
  • Hyperactivity – the child never seems to slow down, constantly talking and fidgeting, and has difficulty staying on task

The American Academy of Pediatrics (AAP) recommends ADHD screening in any child 4 to 18 years of age with a history of academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity.

There are many treatment options, such as:

  • behavior therapy, including parent training
  • medications
  • school accommodations and interventions such as an individual education plan (IEP) or “504 Plan”

For children 6 years of age and older, the AAP recommends both behavior therapy and medication as good options, preferably both together. For preschool-aged children 4-5 years of age who have ADHD, behavior therapy is recommended as the first line of treatment, before medication is tried. Good treatment plans will include close monitoring of whether and how much the treatment helps the child’s behavior, and making changes as needed along the way.

For medical treatment, begin with a low dose of medication and titrate to the dose that provides maximum benefit and minimal adverse effects.

Recommendations for follow-up for children prescribed with ADHD medication are as follows:

  • Initiation phase: A face-to-face follow-up visit within 30 days of ADHD medication initiation in order to review patient responses to the varying doses and monitor adverse effects.
  • Continuation phase: Face-to-face visits to occur initially on a monthly basis, until there is a consistent optimal response, and then every 3 months in the first year of treatment.
  • Maintenance phase: Subsequent visits will depend on the response but should occur at least 2 times per year, until it is clear that target goals are progressing and the patient is stable.

For more about ADHD, providers can refer to the the AAP, the CDC or these additional resources:

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Pharmacy News

Effective August 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 August 1, 2016. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. As of June 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

Provider College administrative training topic for June

Medica CollegeThe Medica Provider College offers educational sessions on various administrative topics. As published last month, the following class is available by webinar for all Medica network providers, at no charge.

Training class topic
"Advanced Claim Edits, Post-Payments and Pre-Payment Edits" (class code: APPE). This class translates the claim submission process into three components: advanced claim edits or “ACE” edits, which take place at the clearinghouse level; post-payments, which are audits constructed after a claim has been processed and paid; and pre-paid edits, which occur during a coding review prior to claim processing and output. Participants will learn how Medica has enhanced its overpayment detection and recovery program through the implementation of a pre- and post-pay claims editing solution. This class will help providers identify if a claim was denied due to one of these edits, what the denial means, and the appropriate process to appeal those denials. It will also go over the new ACE edit policy that Medica launched on January 1, 2016, which flags missing or potentially inaccurate claim information prior to submitting a claim. This ACE policy allows providers to correct their claim in “real time” to help them avoid receiving pre-pay and post-pay adjustments and denials.

Class schedule

Class code Topic Date Time Notes
APPE-WJN ACE, Post-Pay, Pre-Pay June 16 1-3 pm Class code with “WJN” means offered via webinar in June

For webinar trainings, login information and class materials are e-mailed close to the class date. To ensure that training materials are received prior to a class, providers should sign up as soon as possible.

The time reflected above allows for questions and group discussion. Session times may vary based on the number of participants and depth of group involvement.

The registration deadline is one week prior to the class date. To register for the session listed, providers may do either of the following:

Effective August 1, 2016:
Medica to update reimbursement policy

Medica will update the reimbursement policy indicated below, effective with dates of processing on or after August 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®) 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 August 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 payment errors due to clerical entries, HCPCS code descriptors, nature of a service or procedure, nature of equipment, and unlikely clinical treatment. HCPCS codes vary widely in their descriptions of units. To submit the correct number of units, providers should always check the specific HCPCS code description to determine how units are defined.

Here are some examples:

  • HCPCS code A4253 ("Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips")
    Examples of correct billing: Examples of incorrect billing:
          50 strips = 1 unit       50 strips = 50 units
          100 strips = 2 units       100 strips = 100 units
  • HCPCS code A4927 (“Gloves, non-sterile, per 100”)
    Examples of correct billing: Examples of incorrect billing:
          100 gloves = 1 unit       100 gloves = 100 units
          400 gloves = 4 units       400 gloves = 400 units

On or after August 1, 2016, claims with obvious billing errors will be denied for all providers.

Providers may continue to submit appeals with documentation for units denied over the unit assignment. It should be noted that 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.

This updated 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
Made administrative updates to the "Commercial Fee Schedule Update Policy” "Billing and Reimbursement" section, in "Commercial Fee Schedule Update Policy" subsection May 2016
(effective 1/1/16)

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

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SelectCare/LaborCare News

Latest UHC provider bulletin available online

UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (May 2016). Highlights that may be of interest to LaborCare® network providers include:

  • Encouraging patients to use network laboratories to help lower their out-of-pocket costs
  • Bilateral Procedures Policy to be revised — delayed until third quarter 2016
  • CCI Editing Policy coding to be revised — scheduled for third quarter 2016
  • Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency Policy to be revised — scheduled for October 2016

View the May 2016 UHC provider bulletin.

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Posted: May 25, 2016

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