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Provider Medica Connections


October 2016

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

General News

Effective November 1, 2016:
Medica launches new ACO product with Essentia Health

A seventh health care system will soon join the mix of accountable care organization (ACO) product options that Medica offers to its commercial group customers. Essentia Health has collaborated with Medica to create “Essentia ChoiceCare with Medica,” a new plan available starting November 1, 2016, to businesses in northern Minnesota, eastern North Dakota and northwestern Wisconsin. This new ACO plan option will be available through My Plan by MedicaSM or alongside a Medica Choice® Passport plan.

Medica members enrolled in the new ACO plan will have access to Essentia providers in 50 communities as well as these plan benefits:

  • same-day visits with a member of the care team
  • direct access to specialists in the Essentia Health network, without needing a referral
  • “Patient Navigator,” 24/7 customer service providing nurse triage and appointment scheduling
  • a single phone number allowing a one-stop-shop approach for members to contact Essentia Health and Medica about plan benefits, billing, care and appointments

ACOs are networks of health care providers that coordinate with health plans to make health care more efficient and improve the patient experience. Essentia Health, which became an ACO in 2013, is an integrated health system based in Duluth, Minn., with a network of 68 clinics, 15 hospitals and 1,800 physicians and advanced practitioners.

See the fact sheet for this new ACO product

Effective January 1, 2017:
GA modifier to drive liability for investigative services

Effective with January 1, 2017, dates of service, if Medica receives claims for non-covered services that are considered investigative, and there is no GA modifier included, Medica will deny these claims as provider liability.  As a result, where relevant, providers will need to include a GA modifier on such claims when billing Medica to indicate that the patient has assumed liability in writing for the related services. Claims for investigative services are currently denied as member liability whether they include a GA modifier or not.

As needed, providers should be sure to document that their patients accept liability for investigative services. For instance, Medica commercial-group and individual and family (IFB) members can sign forms like the Medica “Pre-Service Payment Consent Form.”

This change on January 1 will apply to claims for all Medica members. It will ensure consistency with billing guidelines used by the Centers for Medicare and Medicaid Services (CMS).

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Clinical News

Effective December 1, 2016:
Medica to implement new coverage policies

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

Confocal laser endomicroscopy for Barrett’s esophagus
Medica has reviewed confocal laser endomicroscopy (CLE) for Barrett’s esophagus and has determined that CLE is investigative and therefore will not be covered.

CLE provides in vivo microscopic imaging of mucosal epithelium during endoscopy. CLE is intended to define cellular structure of lesions with the potential to diagnose mucosal histology in real time. It is purported that this provides the opportunity of reducing number of biopsy specimens collected and/or improving detection of cellular dysplasia. CLE has been purported for many uses, including screening and/or surveillance for Barrett’s esophagus.

Lower limb functional electrical stimulation therapy
Medica recently reviewed lower limb functional electrical stimulation (FES) rehabilitation therapy using stationary equipment and has made the following determinations:

  • FES is covered when used as one component of a comprehensive facility-based rehabilitation program.
  • FES is investigative and therefore will not be covered when used as stand-alone therapy in a facility-based rehabilitation program.
  • FES ergometric cycles are investigative and therefore will not be covered when used in the home setting.

FES is a rehabilitation technique purported to enhance movement or function of organs, muscles, and extremities by applying electrical current to peripheral nerves. FES devices used for lower extremity rehabilitation are available as upright units, supine units, or as bicycles designed for use in both the clinic and home setting. In the clinic setting, FES used as one component of initial facility-based rehabilitation. Examples of applications include, but are not limited to, therapy following spinal cord injury or stroke and for therapy associated with conditions such as cerebral palsy or congestive heart failure.

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

  • See Medica’s coverage policies as of December 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 December 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 December 1, 2016, unless otherwise noted.

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

Name Policy number
Extended Hours Home Care (Skilled Nursing Services) (formerly Extended Hours Home Care (Skilled Nursing Services) For Patients With Medically Complex Or Medically Fragile Conditions; revised to reflect use of MCG® Care Guidelines) III-HOM.01
Genetic Testing for Cardiac Channelopathies (effective 9/21/16; see details) III-DIA.05
Genetic Testing for Cardiomyopathies (effective 9/21/16; see details) III-DIA.07
Genetic Testing for Susceptibility to Hereditary Breast and/or Ovarian Cancer (effective 9/21/16; see details) III-DEV.07
Lumbar Spine Surgeries (effective 8/17/16; administrative update only) III-SUR.34
Spinal Cord Stimulation (effective 9/21/16; see details) III-DEV.23

Coverage policies — New

Confocal Laser Endomicroscopy (CLE)
Functional Electrical Stimulation (FES)

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

Computerized Dynamic Posturography
Food Allergy/Intolerance Testing (in vitro)
Juvenile Cartilage Allograft Tissue Implantation for Articular Cartilage Repair
LTX 3000 (Spinal Unloading Device for Treatment of Low Back Pain)
Mechanized Spinal Decompression Traction Tables for Low Back Pain
Orthotrac Pneumatic Vest (Spinal Unloading Device for Treatment of Low Back Pain)

These documents will be available online or on hard copy:

Due by October 15, 2016:
Quality complaint reports required by State of Minnesota

Medica requires its Minnesota-based network providers to submit second-quarter 2016 quality-of-care complaint reports to Medica by October 15, 2016.

The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form).

Providers can now send reports by e-mail to Otherwise, reports can still be sent by fax to 952-992-3880 or by mail to:

Medica Quality Improvement
Mail Route CP405
PO Box 9310
Minneapolis, MN 55440-9310

Report forms are available by:

Note: Providers submitting a report for multiple clinics should list all the clinics included in the report. Providers who have questions about the complaint reporting process may:

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Pharmacy News

Effective January 1, 2017:
Medica to make important changes to its pharmacy program
          All drug lists will be updated

By January 1, 2017, all Medica members will transition to Medica’s new pharmacy program, to be administered by CVS Caremark, as previously published. Medica is also making upcoming changes to its pharmacy program, such as changes to drug coverage, which will have an impact on many Medica members. Pharmacy program changes starting January 1 include:

  • All Medica member populations (commercial group, individual/family, Medicare and Medicaid) will have new drug lists.
  • A majority of non-Medicare Medica members treated for diabetes will be affected by coverage changing for diabetic supplies and insulin (look for more details about this coming soon).
  • Other changes will affect a small portion of Medica members, and will involve changes to drug lists, drug tiers, prior authorization, step therapy, and quantity limits, as well as a few minor changes to Medica's network of pharmacies.

Learn more about these changes and access resources at This new website contains details such as:

  • New drug lists effective January 1
  • Dates for upcoming webinars hosted by the Medica Provider College (see below)
  • A timeline showing transition outreach activities to providers and members
  • New prior authorization forms
  • Updated policies and procedures
  • Answers to frequently asked questions
  • Updated product fact sheets
  • Contact numbers

Providers are encouraged to share this information with their office and clinical staffs. Medica will be notifying its affected members in the coming weeks, so they may soon ask their providers about these upcoming changes. Medica wishes to thank providers for helping to ensure a smooth transition as Medica switches to a new pharmacy program. The shared goal is to minimize any impact to patients who need to change prescriptions.

Note: Most provider groups using an electronic medical record (EMR) should receive updated EMR drug list information for their Medica patients as of January 1.

As a reminder, MedImpact continues to administer Medica’s pharmacy program for the majority of Medica members through the end of 2016.

Medica offers new infusion therapy program for members

Medica has started offering its commercial members a new option for infusion therapy. Through "Site of Service," administered by Magellan Rx, this program offers in-home therapy as a lower-cost alternative. The program is intended for members currently receiving infusion therapy in an outpatient hospital setting. The in-home option adds more convenience for members. Plus, infusions at home and at provider offices reduce potential exposure to hospital-based infections. While members in need of infusion therapy have open access to receive infusions at hospitals, in provider offices or in their home, most members aren't fully aware that in-home infusion might be appropriate and available to them.

For all eligible members, the convenience of in-home infusion eliminates both the time needed to travel to an infusion site and the time a member has to take off from work for infusions. Home infusion should appeal especially to members who live in rural areas.

Magellan identifies members receiving hospital-based infusion therapy from a set list of drugs that are safe to be administered at an alternate site or even in the home. Magellan’s care team works with members and their physicians to offer options regarding clinically appropriate and convenient sites for the infusions. While it may make sense for infusions take place in some members’ homes, a change to a clinic setting might make sense for others. Magellan’s registered nurse care managers talk with members to help them better understand their disease, drug therapy, the availability of different infusion sites, infusion benefits and support services. If a member decides to change the site of infusion, the nurse would reach out to the provider to help make it happen.

Providers who have questions about this program can call Magellan Rx at 1-800-424-1845.

Effective December 1, 2016:
Medica to add new UM policies for medical pharmacy drugs

Medica will soon implement the following new medical pharmacy drug utilization management (UM) policies, effective with December 1, 2016, dates of service. Prior authorization will be required for the corresponding medical pharmacy drugs.

Medical pharmacy drug UM (prior authorization) policies — New
Prior authorization will be required.

Drug code Drug brand name Drug generic name
 J0490  Benlysta  belimumab
 J1599  IVIG  immune globulin
 J3060  Elelyso  taliglucerase alfa
 J0220  Myozyme  alglucosidase alfa
 J0180  Fabrazyme  agalsidase beta
 J1931  Aldurazyme  laronidase
 J1743  Elprase  idursulfase
 J1458  Naglazyme  galsulfase
 J0221  Lumizyme  alglucosidase alfa
 J3385  VPRIV  velaglucerase alfa

These policies will apply to Medica commercial, Minnesota Health Care Programs (MHCP) and individual and family business (IFB) members, but not to Medica Medicare members. All of these policies will be subject to pre-payment claims edits as well.

The new medical pharmacy drug UM policies above will be available online or on hard copy:

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Administrative News

Provider College administrative training topic for October

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
"Pharmacy Benefit Manager Changes" (class code: PBM)
This webinar will give providers more detail around Medica’s switch to CVS Caremark as its new pharmacy benefit manager (PBM). It will include an overview of the transition timeline from September 2016 through January 2017 and what activities are occurring during that time, such as provider and member outreach. This training will also outline pharmacy program changes such as prior authorization and billing parameters related to the new PBM, new drug lists coming on January 1, 2017, and contact information for CVS Caremark so providers can request medication exceptions and appeals, when needed. The class will also cover the resources available to make this transition as seamless and efficient as possible for both providers and their Medica patients.

Class schedule

Class code Topic Date Time Notes
PBM-WO PBM Changes Oct. 18 11 am - noon Class code with “WO” means offered via webinar in October

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. Online registration is now available!

Register online for the session above.

Effective November 12, 2016:
Medica to expand enhanced process for overpayment recovery
Greater overpayment clarity also planned for PRA 

To improve operational efficiencies and status communication when it comes to overpayment of claims. Medica will expand its enhanced overpayment recovery process and improvements to the provider remittance advice (PRA), tentatively scheduled to begin with November 12, 2016, dates of processing. These changes, which occur for some Medica member claims already, will be applied more broadly, affecting claims for most Medica members. The changes should both simplify administrative processes and improve communications to providers about overpayment recovery. 

The enhancements will result in:

  • advanced notification letters for overpayment recovery requests to include claim details
  • PRAs with more detail including a new “Overpayment Reduction Detail” page that indicates the amount of the original adjustments, all offsets, and the current balance
  • automatic offsets of overpayments against future claim payments
  • current claims being allowed to process against a negative balance
  • a quicker turnaround time on claims being offset

Providers will have 30 days to respond to overpayment notification letters by sending in either a refund check or a written inquiry. Providers who choose not to respond will have overpayment recovery claims offset against future claim payments after 45 days.

Effective January 1, 2016:
Medica revises reimbursement policy

Medica has updated the reimbursement policy indicated below, effective with January 1, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.

Reimbursement policies —Revised
These versions replace all previous versions.

Bilateral (updated code list)

This revised policy is available online or on hard copy:

Effective August 28, 2016:
Medica revises reimbursement policy

Medica has updated the reimbursement policy indicated below, effective with August 28, 2016, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.

Reimbursement policies —Revised
These versions replace all previous versions.

Once in a Lifetime Procedures (updated code list)

This revised policy is available online or on hard copy:

Providers need to regularly update demographic data, per CMS

As previously published, Centers for Medicare and Medicaid Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them, beginning in 2016. The new rules state, among other things, that provider directories be accurate and updated regularly, in compliance with CMS guidance. 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.

Misdirected IFB claims result in unwarranted member charges

As a reminder, all electronic claims for Medica individual and family business (IFB) members need to be submitted using payer ID #12422. IFB members are identifiable by the group/policy number "IFB" on their ID cards. If providers use the wrong payer ID, these claims can be denied, not allowing member benefits to be correctly applied. When this happens, providers often bill these IFB members incorrect charges that are too high, as they’re for a greater portion of health care costs than the members should pay.

As long as providers submit IFB claims using payer ID #12422, Medica can process these claims more efficiently, resulting in fast, accurate payments to providers. As a bonus, this should also make these patients happier, since they won’t receive unnecessary bills. 

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 continuity-of-care requirements, specifying Wisconsin requirements for Wisconsin providers “Health Management and Quality Improvement" section, in "Provider Responsibilities" subsection, under "Continuity of Care” September 2016

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

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SelectCare/LaborCare News

Effective January 1, 2017:
Aetna terminates its contract as TPA for SelectCare network

Aetna has given notice to Medica that it is terminating its third-party administrator (TPA) contract at the end of this year, affecting a majority of current Medica SelectCareSM members effective beginning with January 1, 2017, dates of service. As a result, starting next year, SelectCare network providers will need to contact Aetna directly for all inquiries about these enrollees, including claims, appeals, rate disputes and reconsiderations.

Standard claim-submission timeframes continue to apply for SelectCare through the end of 2016, as do standard Aetna dispute-resolution procedures and appeals policies and timeframes. Questions on 2016 SelectCare claims should continue to go to Aetna after January 1, 2017, since Aetna will handle all SelectCare claim- and appeal-related issues through June 30, 2017, during the claims run-out period.

For more Aetna information about claims and appeals, providers can:

  • Refer to Aetna’s website.
  • Contact Aetna at 1-888-632-3862. (If unable to get a resolution, escalate issues to an Aetna supervisor.)

Note: Current SelectCare members affected by this change will receive new ID cards reflecting their new network and product offering effective January 1, 2017.

Latest UHC provider bulletin available online

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

  • OptumHealth develops online preventive health tools for behavioral health conditions — now effective
  • ICD-10 look-up tool to end operation — scheduled for September 2016
  • E/M codes for billing by nonphysician practitioners to be revised — scheduled for December 2016

View the September 2016 UHC provider bulletin.

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Posted: September 28, 2016

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