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Provider Medica Connections


September 2016

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

General News

Annual notice:
Medica encourages members to get flu shots


Each year, Medica encourages its members to get seasonal influenza shots, and will do so again by promoting them through member newsletters, worksite flu-shot clinics, and targeted member mailings this fall. In addition to providing protection against H1N1 (“swine flu”), this year's vaccine is available in both trivalent and quadrivalent variations that protect against other strains of the influenza virus. Health care professionals should talk to their patients about which vaccine is appropriate for them.

Vaccine priorities
The U.S. Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommend that everyone 6 months of age and older get a flu vaccine each year. It is especially important for the following individuals to receive a flu vaccine, either because they are at higher risk for infections or complications from the flu, or they live with or care for those at higher risk:

  • Pregnant women
  • Household contacts and out-of-home caregivers of children younger than 5 years of age
  • People 50 years of age and older
  • People of any age with certain chronic medical conditions
  • People who live in nursing homes and other long-term-care facilities
  • People who live with or care for those at high risk for complications from flu, including health care workers
  • Household contacts of persons at high risk for complications from the flu

Pharmacist-administered vaccination
Medica members may be able to receive their flu vaccination through a Medica network pharmacy. Inquiries can be directed to a member's local pharmacy.

Billing for shots
Clinics should use their regular billing methods for flu shots. To ensure full coverage, Medica members must receive shots from a Medica network provider.

When submitting claims for flu shots, providers should use applicable codes of the International Classification of Diseases (ICD-10-CM), Common Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS). Medica will accept codes for reimbursement as outlined by CDC.

More information
More details on seasonal flu vaccine are available online:

Providers who have questions or comments about Medica flu and pneumonia prevention programs may call the Medica Provider Service Center at 1-800-458-5512. In the event of a vaccine shortage, providers are encouraged to refer to the Minnesota Department of Health (MDH) website.

Effective September 1, 2016:
CVS Caremark to start as new PBM for IFB members
CVS Caremark now handles IFB drug prior authorization

As announced previously, Medica will begin transitioning to a new pharmacy benefit manager (PBM) in the coming months. Starting September 1, 2016, CVS Caremark will be the new PBM for Medica’s individual and family business (IFB) members. CVS Caremark will become PBM for all other Medica members on January 1, 2017.

To request a drug prior authorization for Medica IFB members, providers can: 

  • Fax prior authorization forms to CVS Caremark at 1-888-836-0730.
  • Call CVS Caremark at 1-855-582-2022.

Providers can also fax appeals to CVS Caremark at 1-855-245-8333.

Medica will work with MedImpact to transfer existing prior authorizations over to CVS Caremark, and continue existing prior authorizations through their end date. If an IFB member is starting a new medication on or after September 1, 2016, CVS Caremark will handle any required prior authorization. Access drug prior authorization forms for both CVS Caremark (coming soon) and MedImpact at

Providers can get more details about Medica’s PBM transition in a couple of ways:

As a reminder, MedImpact remains the PBM for all non-IFB Medica members through the end of 2016.


How to bill for community paramedic services for MHCP members

As a reminder, Medica covers community paramedic services provided to Minnesota Health Care Programs (MHCP) members. Under this benefit, certified community paramedics can bill under the national provider identifier (NPI) number of their provider group's ambulance medical director, using a CMS-1500 paper claim form or the professional (837P) electronic claim format. The following billing specifications apply:

  • Indicate place-of-service code 12 (home). 
  • Code T1016 with modifier U3.
  • Bill in 15-minutes increments, where 1 unit = 15 minutes.
  • Bill supplies primary to the encounter separately (supplies used by the community paramedic in direct relationship to the illness or injury are considered incidental to the service and not separately billed to Medica).
  • Do not bill for travel or mileage.

Community paramedic services must be part of a care plan ordered by a primary care provider and must meet other requirements. For more information, providers can refer to details at the Minnesota Department of Human Services (DHS) website.

Note:  Community paramedic services do not include ambulance services, and ambulance codes are not billable under the MHCP benefit for community paramedic services.

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Clinical News

Counseling parents about their children's health

Immunizations, nutrition and exercise are critical factors for children’s health. There is long-term value for patients themselves as well as to society at large. 


All health care professionals providing care to newborns, infants, children and adolescents meet frequently with parents or caregivers who have concerns about vaccines to be administered. Some have questions about the vaccine itself and others do not want the vaccine to be given to their child. It can be a challenge to address all the concerns that the parent or caregiver may have.

Key points to remember for discussions between a provider and a child’s parent or caregiver:

  • A Vaccine Information Statement (VIS) needs to be provided to a parent or legal representative every time a vaccine is given.
  • Every discussion of a vaccine risk and benefit plus risks of not vaccinating should be documented in the patient chart. 
  • Each vaccine should be strongly recommended by the provider to parents, including the human papillomavirus (HPV)vaccine. 
  • Be sure to listen to parents’ concerns and acknowledge them in a non-confrontational manner.
  • Promote partnership with parents in decision-making and personalize these relationships.
  • Discuss state laws for school entry and the rationale of them.
  • If the parent refuses vaccinations for their child, even after the discussion about the benefits and risks for not vaccinating, document the discussion and have the parent sign a waiver affirming the decision not to vaccinate.

Concerns about vaccine safety have risen, posing challenges for today’s pediatricians. Concerns about vaccine safety are more common among parents of under-immunized children, but many parents of fully immunized children also express concerns.

Nutrition and physical activity
Good nutrition and physical activity are important elements contributing to a child’s healthy lifestyle. Obesity is a growing problem among children in America. The “5-2-1-0” program helps as a guide for children to achieve a healthy, active lifestyle:

    5 - Eat at least 5 fruits and vegetables a day.
    2 - Limit recreational screen time to 2 hours or less a day.
    1 - Get 1 hour or more of physical activity every day.
    0 - Restrict soda and sugar-sweetened sports and fruit drinks.  Drink water and fat-
         free/skim/1% milk.

As long as children are getting three relatively balanced meals per day plus two snacks, their weight should be fine. As long as parents stick to healthy food choices from the major food groups and encourage exercise, a child’s weight should take care of itself.

Parents are important role models for their children. Parents need to encourage healthy habits in their children, including diet and exercise. Physical activity should become as routine a part of their lives as healthy eating and sleeping. Nutrition is important to normal growth processes and parents should make every effort to ensure their child consumes a well-balanced diet.

Find more information on the 5-2-1-0 program and from the American Academy of Pediatrics.

Effective November 1, 2016:
Medical policies and clinical guidelines to be updated

Meidca 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 November 1, 2016, unless otherwise noted.

UM policies — Inactivated

Name Policy number
Humanitarion Device Exemption (effective 8/1/16) III-DEV.18

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

Inhaled Nitric Oxide Therapy
Magnetoencephalography/Magnetic Source Imaging
Access Techniques for Lumbar Interbody Fusion (effective 8/17/16; see details; formerly Minimally Invasive Access Techniques for Lumbar Interbody Fusion)  
 Pelvic Vein Embolization

These documents will be available online or on hard copy:

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Pharmacy News

The need for translation services in community pharmacies

With over 23 million Americans having limited English proficiency, language differences can pose a barrier to achieving positive health outcomes. These communication challenges can have a negative impact on the patient’s understanding of their care and treatment. In a study done at a clinic in Minneapolis, 54 percent of non-English-speaking patients had an adherence issue with their medications due to not understanding the directions.

Although translation services are not legally required, counseling patients is required, so most pharmacies do have access to translation services upon request. Despite this availability, a survey of community pharmacies in Milwaukee, Wis., found only about half often provide translated prescription labels or printed information. And about two-thirds of these pharmacies rarely verbally communicated with non-English speaking patients in other languages. This leaves a huge opportunity for improved communication with non-English-speaking patients.

Providing information in a patient’s primary language can improve communication to ensure that patients are able to use their medications appropriately and safely. The biggest suggestion community pharmacies indicate is that it is helpful if the prescriber indicates the patient’s preferred non-English language on the prescription.

Here are additional tips for prescribers and pharmacists on how to help improve patient understanding:

  • Advertise language accommodations __ Post signs in the waiting area and around the facility to help increase patient awareness about the services offered.
  • Offer translated versions of frequently used materials __ This can improve efficiency and accuracy of documentation and education.
  • Note in the profile if the patient is non-English-speaking __ Often staff will have to ask the patient their preferred language, as this isn’t usually volunteered. Doing so proactively alerts other members of the team about the need for accommodations.

See more information on this topic from the American College of Physicians.

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Administrative News

Provider College administrative training topic for September

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

Training class topic
"The Medica Model of Care for Its MSHO Members" (class code: MSHO).  This webinar gives details about Medica’s model of care for members enrolled in Medica DUAL Solution®, Medica’s product for enrollees in the Minnesota Senior Health Options (MSHO) program. This product is for members who are eligible for both Medicare and Medicaid and are 65 years of age and older. This training will provide information about benefits available to members in the Medica MSHO product, the role of care coordinators in the member’s care, and the importance of providers in an MSHO member’s interdisciplinary care team.

Class schedule

Class code Topic Date Time Notes
Model of Care
Sept. 22 10-11:30 am Class code with “WS” means offered via webinar in September

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 November 12, 2016:
Medica to implement new reimbursement policy

Medica will soon implement the new reimbursement policy indicated below, effective on or after November 12, 2016, dates of service. Such policies define when specific services are reimbursable based on the reported codes. 

T-status codes
Consistent with the Centers for Medicare and Medicaid Services (CMS), Medica considers Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes in the National Physician Fee Schedule (NPFS) with a status indicator of T as bundled into any other payable service that is assigned a status indicator of A, R, or T. This is applicable only when submitted by the same physician or health care professional for the same patient on the same day. There are no modifier overrides that will allow payment of T-status codes when billed with another payable code.

NPFS status-code definitions:

 A Active Code.  These codes are paid separately under the physician fee schedule, if covered.  There will be relative value units (RVUs) for codes with this status.
R Restricted Coverage.  Special coverage instructions apply. If covered, the service is carrier priced. (Note: The majority of codes to which this indicator will be assigned are the alpha-numeric dental codes, which begin with "D.")
T Injections. There are RVUs and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made.

If two T-status codes are billed on the same date of service by the same individual physician or other health care professional, the code with the lower RVU will bundle into the code with the higher RVU.

T-status codes to be included in this new reimbursement policy:

 36591   Collection of blood specimen from a completely implantable venous access device
 36592 Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified
36598  Contrast injection(s) for radiologic evaluation of existing central venous access device, include fluoroscopy, image documentation and report 
 96523 Irrigation of implanted venous access device for drug delivery systems
 G0117 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist 
 G0118  Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

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

Effective November 12, 2016:
Medica to revise reimbursement policy

Medica will soon update the reimbursement policy indicated below, effective on or after November 12, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes. 

Multiple procedure reduction
To further align with the Centers for Medicare and Medicaid Services (CMS), Medica will begin to consider all procedure codes with a CMS multiple procedure indicator of 2 or 3 in the National Physician Fee Schedule Relative Value File as eligible for multiple procedure reduction when reported with other procedure codes subject to reductions. When multiple procedures are performed on the same day by the same physician and/or other health care professional, a reduction in reimbursement for secondary and subsequent procedures will occur.

Currently, procedure codes with a multiple procedure indicator of 2 or 3 that do not have a CMS relative value unit (RVU) assigned and are not assigned a gap value are excluded from reduction by Medica. Effective on or after November 12, 2016, dates of processing, Medica will begin considering procedure codes with a CMS multiple procedure indicator of 2 or 3 and with an RVU of 0.00 as secondary or subsequent procedures and therefore eligible for reduction.

Procedures assigned a CMS multiple procedure indicator of 2 or 3 are subject to the multiple procedure concept, and the procedure code assigned the highest RVU will be considered the primary procedure. Note: If two or more procedure codes are assigned an RVU of 0.00, the procedure code with the highest billed charge will be considered the highest-ranked procedure.

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

Correct coding related to anesthesia reimbursement policy

The following is a reminder for providers regarding correct coding as reflected in the Anesthesia reimbursement policy. Such policies define when specific services are reimbursable based on the reported codes.

Current Procedural Terminology (CPT®) codes for qualifying circumstances for anesthesia (99100, 99116, 99135 and 99140) are used to indicate that anesthesia was provided under a particularly difficult circumstance. The add-on codes are submitted in addition to the code for the anesthesia service (00100-01999). An anesthesia modifier (AA, AD, QK, QX, QY, or QZ) must be appended to the qualifying circumstances codes in addition to the anesthesia codes.

Reimbursement policies are available online or on hard copy:

Provider requirements related to adverse health care events

As a reminder, if an adverse health care event (or “never event”) involving a Medica member occurs, facilities are expected to follow the Adverse Health Care Events reimbursement policy from Medica. According to the policy: “Facilities are prohibited from billing members for services associated with an adverse health care event. If an adverse health care event involving a Medica member occurs, facilities are required to submit an Adverse Health Care Event Identification Form to Medica.” In addition, facilities must comply with and maintain policies and procedures that address the reporting of adverse health care events in accordance with Minnesota law.

For further details, including a description of each applicable adverse health care event, providers can refer to the Adverse Health Care Events policy

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 updates to compliance requirements, clarifying that Medicaid providers need to follow relevant Minnesota state definition of “medical necessity"
"Special Contracting Requirements" section, in "Government Program Requirements" subsection, under "Provider Requirements for Medicare, Medicaid and Government Programs" August 2016
(effective 8/10/16)
Adding CVS Caremark pharmacy benefit manager (PBM) references to reflect PBM change for IFB "Pharmacy Services” section, under "Pharmacy Resources"; also in “Medica Points of Contact” section, under “Other Points of Contact”; also in “Product Portfolio” section, under “Individual and Family Products" August 2016 (effective 9/1/16)

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

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SelectCare/LaborCare News

Latest UHC provider bulletins available online

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

  • Reminder on new Consultation Services Policy — now effective
  • Prior authorization requirement for genetic testing — delayed indefinitely
  • Clinical guidelines for neonatal resource services to be revised — scheduled for October 2016
  • Nonphysician Health Care Codes Policy to be revised — scheduled for fourth quarter 2016
  • Ambulatory Policy to be revised — scheduled for fourth quarter 2016

View the July 2016 UHC provider bulletin and August 2016 UHC bulletin.

Posted: August 24, 2016

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