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Provider Medica Connections


November 2016

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

General News

Effective January 1, 2017:
Medica to offer new IFB product in Kansas

Medica is expanding its service area for individual and family business (IFB) plans. Effective January 1, 2017, Medica will offer the new IFB product “Medica ConnectSM” in Kansas, both on and off the federal Marketplace exchange. To support this new product, Medica has leased two of the largest provider networks in Kansas: ProviDRs Care and Preferred Health Professionals (PHP). ProviDRs Care is owned by the Medical Society of Sedgwick County while PHP is a subsidiary of Blue Cross and Blue Shield of Kansas City.

A key feature of the Medica Connect product is the relationship Medica has formed with Mayo Clinic for a Centers of Excellence program. The program allows patients to receive care at Mayo Clinic with Medica providing a travel, lodging and meal stipend for the patient and a companion, to provide peace of mind to individuals and families experiencing significant health care issues.

Providers who have a contract with Medica and who provide care to a Medica Connect member will be reimbursed at their Medica Choice® rates.

For more details about this product, including a copy of the member ID card, see the Medica Connect Fact Sheet.


Effective January 1, 2017:
Medicare Cost plans to include several benefit changes

Effective January 1, 2017, Medica Prime Solution® plan designs will have several changes. These include several member cost-sharing increases for certain services covered by these Medicare Cost plan options from Medica. One example is a change to member liability for inpatient hospital stays. It is important that members are aware of these upcoming changes and take the opportunity to explore all plan options available to them during the annual enrollment period that runs from October 15 to December 7, 2016. Highlights of plan changes:

  • Hospital inpatient copays will change for Enhanced, Basic, Value and Thrive plans from per-stay to per-day cost-sharing per benefit period. Member liability will be capped at the Medicare Part A deductible amount, which is $1,288 for 2016. Thrift plan benefits remain the same, at $600 per stay.
  • Copays will change for specialist office visits, urgent care and chiropractic services as part of Enhanced and Thrive plans.
  • Premiums will be reduced up to 24 percent on Medica’s bundled medical-Part D plans for 2017. There are eight bundled plans to choose from.
  • Deductibles for Part D coverage will be lowered on four plans, and three plans continue to offer $0 deductibles.

In addition, with Medica’s transition to a new pharmacy program and a new pharmacy benefit manager (PBM), the Part D formulary will change as of January 1, 2017. Medica Prime Solution members with Part D coverage received a copy of the new formulary in their Annual Notice of Change mailing this fall. As part of the transition to Medica’s new pharmacy program, these members will see several changes to their Part D medication coverage:

  • All Medica Part D plans will use the same broad 5-tier formulary that covers more than 3,400 prescription drugs. Tiers were determined by the cost of the drug; generic and brand-name drugs can be found across various tiers.
  • Tier 1 medications will include commonly prescribed medications for the senior population including generic and brand-name drugs.
  • Copays for Tier 1-3 prescription drugs will be reduced on most plans.
  • Members affected by formulary tier changes or utilization management changes (such as quantity limits, step therapy or prior authorization requirements) are receiving a personalized letter providing them with information about applicable changes and alternatives available.

All Medicare members will receive a new ID card in December 2016 with new PBM information. Medica anticipates higher-than-average plan switching during the annual enrollment period, so providers are encouraged to ask for new patient ID cards after January 1 to be sure to have current plan information.

Learn more about 2017 plan options.

Effective February 2, 2017:
Medica to implement new program for claim validation review

Effective early in 2017, Medica plans to implement a new program to undertake claim validation review for several types of claims, which will be administered by SCIO Health Analytics. This “payment integrity” program aims to reduce billing errors, as required by the Centers for Medicare and Medicaid Services (CMS). Initially the validation review will include claims for inpatient hospital services, home health care, skilled nursing facility (SNF) charges and durable medical equipment (DME) charges, as well as others. This new claim validation review program will apply to claims for most Medica members.

This claim validation program will review claims and compare them to original medical records from providers’ offices to validate the billing. SCIO Health Analytics will send initial medical record requests out to providers in February 2017. There may be a one-time 12-month look-back when the program begins, and then it will involve an ongoing monthly review after that. After the review and reconsideration periods for flagged claims, if the services billed are found to not match the services provided, Medica may retroactively adjust or deny corresponding payments, offsetting any overpayments against subsequent claim payments from Medica. This claim impact may also result if providers do not respond in a timely manner or lack supporting data related to the claims submitted.

Note: All correspondence and appeals for this new claim validation review program will be handled by SCIO Health Analytics. Providers will continue to have the ability to appeal payment decisions.

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Clinical News

Effective January 1, 2017:
Prior authorization to be required for whole exome sequencing

Beginning with January 1, 2017, dates of service, Medica will require prior authorization for whole exome sequencing as outlined below. By instituting prior authorization, Medica aims to support members and providers in making evidence-based decisions about appropriate, medically necessary care.

Diagnostic whole exome sequencing, including trio testing, will be deemed medically necessary and therefore will be covered when all of the following criteria are met:

  • The test is ordered by a board-certified medical geneticist.
  • One of the following criteria is met:
    • The individual’s phenotype is likely explained by a genetic cause as demonstrated by either multiple abnormalities affecting unrelated organ systems or an abnormality affecting a single organ system when family history is strongly suggestive of a genetic disorder.
    • Other potential causes (e.g. environmental exposure, injury, infection) have been ruled out.
  • Standard biochemical and genetic tests (e.g., karyotyping, single gene testing, chromosome microarray testing) have failed to identify a diagnosis.
  • The clinical presentation does not fit a well-described syndrome for which single-gene or targeted panel testing is available.
  • Test results will have a direct impact on clinical decision-making and/or health outcomes.
  • The individual has undergone pre-test genetic counseling and informed consent.

As of January 1, 2017, Medica will implement a new utilization management (UM) policy for this genetic test, which will require prior authorization. This new UM policy will address these changes and will replace the Medica coverage policy “Whole Exome Sequencing.” The new UM policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage. 

On January 1, the Medica Prior Authorization List will also be updated to reflect this change. As a reminder, Medica requires that providers obtain prior authorization before rendering services. If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability.

The complete text of the new UM policy above will be available online or on hard copy:

  • See Medica’s UM policies as of January 1, 2017; 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, 2017:
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, 2017, unless otherwise noted.

Note: The Medica product for Minnesota Senior Health Options (MSHO) will require prior authorization for several procedures effective with January 1, 2017, dates of service. As noted below, the affected UM policies will reflect this change applying to Medica DUAL Solution® members. Providers should follow these Medica policies only when no National Care Determination/Local Care Determination (NCD/LCD) exists; if an NCD or LCD exists, it should be followed and would be available at

UM policies — New

Name Policy number
Whole Exome Sequencing III-DIA.13

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

Name Policy number
Adult Gender Reassignment Surgery III-SUR.20
Autologous Cultured Chondrocyte (CarticelTM) Transplantation for the Knee III-SUR.35
Blepharoplasty, Blepharoptosis Repair and Brow Lift (effective for MSHO) III-SUR.29
Cervical Spine Surgeries (effective for MSHO) III-SUR.37
Home Health Aide III.HOM.02
Inpatient Rehabilitation Facility (Acute Rehabilitation) (effective for MSHO) III-INP.05
Knee Arthroplasty/Replacement III-SUR.41
Long-Term Acute Care Hospital (LTACH) (effective for MSHO) III-INP.04
Lumbar Spine Surgeries (effective for MSHO) III-.SUR.34
Medicaid Home Care Nurse (HCN) Services III-HIM.05
Medicaid Home Health Aide III-HOM.04
Personal Care Assistance III-HOM.03
Positron Emission Tomography (PET) Scan (update to also apply for MSHO) III-DIA.12
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) (effective for MSHO) III-DIA.08
Sacral Nerve Stimulation III-DEV.22
Varicose Vein and Venous Insufficiency Treatments (effective for MSHO) III-SUR.26
Wheelchairs, Scooters and Accessories (effective for MSHO) III-DEV.25

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

Digital Breast Tomosynthesis (effective 10/19/16; see details)
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications and Soft Tissue Injuries
Gene Expression Profiling for Accessing Cancers of an Unknown Origin
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
Telemedicine (formerly Telehealth; administrative update only)
Virtual Care (formerly E-visits; administrative update only)

These documents will be available online or on hard copy:

Steps to help patients take control of diabetes

According to a 2012 study published by the American Diabetes Association (ADA), the economic cost of diabetes in the United States was $245 billion. The costs were estimated to be $176 billion in direct medical costs and $69 billion in reduced productivity. This represents a huge burden on society and is likely increasing.

What can providers do to help decrease the burden of this disease and to help their patients? The ADA recommends that patients with diabetes are monitored for tight control of their A1C. Ideally, this means levels between 70 and 130 mg/dl before meals, and less than 180 two hours after finishing a meal.

The U.S. Preventive Services Task Force (USPSTF) recommends that providers screen for early detection. USPSTF recommends screening for abnormal blood glucose as part of a cardiovascular risk assessment in adults 40 to 70 years of age who do not have any obvious symptoms of diabetes.

The National Institute of Diabetes and Digestive and Kidney Diseases (part of the National Institutes of Health, or NIH) suggest that providers do the following:

  • Educate patients on diabetes.
  • Test patients’ A1C, monitor their blood pressure and monitor cholesterol levels.
  • Encourage patients to eat well, reduce their stress (taking walks, meditation, hobbies, etc.), be active, and get into routines for regular provider visits, foot checks, and eye exams.

The Institute for Clinical Systems Improvement (ICSI), meanwhile, recommends the following for ongoing management:

  • Perform a targeted annual history and physical exams.
  • Encourage patients to have a dilated eye exam.
  • Screen for retinopathy since up to 21 percent of patients with Type 2 diabetes have retinopathy.
  • Perform renal assessment and nephrology assessment including screening for microalbuminuria.
  • Screen for peripheral vascular disease since it has been found that as many as 36 percent of patients with diabetes have lower-extremity peripheral arterial disease.
  • Assess cardiovascular and cerebrovascular risks.
  • Encourage patients to receive hepatitis B and pneumococcal vaccines and receive an annual influenza vaccine.

Providers can have an immense impact on their patients by supporting them as they care for their condition, educating them on diabetes and following recommended screening and preventive steps. As a result, diabetes will be less problematic for patients and society as a whole.

For more details, refer to the ADA, USPSTF or ICSI.

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Pharmacy News

Effective January 1, 2017:
Diabetes product coverage to change with new pharmacy program
    Medica members not on a Part D drug plan will see an impact

Effective January 1, 2017, Medica is making changes to its pharmacy program, such as changes to drug coverage, which will have an impact on many Medica members. One of the most significant coverage changes will apply for non-Medicare patients who manage diabetes, as coverage for blood glucose test strips will change for non-Part D drug plans. Coverage will change for insulin products as well, which will depend on the member’s drug list. 

New ‘OneTouch’ program for diabetes management
A majority of members with commercial (both small and large group), individual/family and Minnesota Health Care Programs plans who are treated for diabetes (and do not have a Medicare Part D drug plan) will be affected by this upcoming coverage change. Medica will offer these members a new diabetic supply-alignment program in partnership with Johnson & Johnson. This “OneTouch” program for diabetes management includes innovative products used to enhance the quality of care, helping both patients and providers. Medica’s goal is to make it easier and more efficient to care for diabetic patients, and OneTouch should help Medica and its network providers achieve this.

Medica will be reaching out to affected members soon, instructing them on how to obtain a new blood glucose meter at no cost. Starting December 1, 2016, Medica members will be able to call CVS Caremark, Medica’s new pharmacy benefit manager, at 1-800-588-4456 to request a new OneTouch meter. For all Medica members who are converting to the new meter, prescribers will need to write a prescription for OneTouch test strips and other diabetic supplies to fill on or after January 1, 2017.

Other pharmacy changes coming on January 1
As a reminder, Medica is making several changes to its pharmacy program starting January 1, 2017. For example, all Medica member populations (commercial group, individual/family, Medicare and Minnesota Health Care Programs) will have new drug lists. Other changes will affect a small portion of Medica members, and will involve changes to 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

Providers are encouraged to share this information with their office and clinical staffs. Medica is notifying affected members, who may ask their providers about these upcoming changes. Medica wishes to thank providers for helping to ensure a smooth transition for Medica patients who will need to change their prescriptions.

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

Also as a reminder, MedImpact continues to administer Medica’s pharmacy program for the majority of Medica members through the end of this year.

(Update to “Medica to make important changes to its pharmacy program” article in the October 2016 edition of Medica Connections.)


Effective January 1, 2017:
Medica to make annual update to Part D drug formularies

Medica has made annual decisions on drugs that will either be removed from the Medica Medicare Part D drug formularies or be subject to a change in preferred or tiered cost-sharing status effective January 1, 2017. The 2017 Part D formularies for Medica Prime Solution® members and Medica DUAL Solution® members are posted on Medica will also notify affected members prior to January 1 formulary changes. These members will be encouraged to review their formulary to see if any of their medications are changing, especially if there were changes to their medications after June 30, 2016.

Providers can also refer to a comprehensive list of all previous Medica Medicare Part D drug formulary changes. View Medicare Part D drug formulary changes on

The Medica Medicare Part D drug formularies are available online or on paper:

Medication request forms
Requests for formulary drug exceptions (or prior authorization) needed for January 1, 2017, dates of service can be submitted to CVS Caremark beginning December 1, 2016. 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 for prescriptions effective January 1, providers can:

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Network News

Effective January 1, 2017:
Medica to update Medicare physician fee schedule

Beginning with January 1, 2017, 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 2017 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.

Second-quarter PCR checks to be mailed in October 2016

By the end of October 2016, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the second quarter of 2016. This represents a 100-percent return of the second-quarter 2016 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of April 1, 2016, through June 30, 2016, and dates paid of April 1, 2016, through September 30, 2016. 

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Administrative News

Effective January 1, 2017:
Medica to implement new reimbursement policy

Medica will soon implement the new reimbursement policy indicated below, effective with dates of service on or after January 1, 2017. Such policies define when specific services are reimbursable based on the reported codes.

Medica will soon implement a new reimbursement policy for telemedicine that applies to Medica's commercial, Medicare and individual and family business (IFB) members. The telemedicine policy for Minnesota Health Care Programs (MHCP) members that went into effect on January 1, 2016, remains unchanged.

The current Telemedicine policy addresses payment for the delivery of health care services or consultations for members on an MHCP plan. As of January 1, 2017, Medica will implement a separate Telemedicine policy for all non-MHCP plans. This similar but new policy will address telemedicine services while a patient is at an originating site and the licensed health care provider is at a distant site. This policy will also define “Originating Site” and “Distant Site,” as well as outline eligible services and those provider specialties eligible to perform telemedicine services.

This new 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
Will make update to reflect upcoming change with regard to billing for investigative services, where such claims will be denied as provider liability if providers do not submit a GA modifier (as published last month) “Health Management and Quality Improvement" section, in "Medical Policies" subsection, under "Coverage Policies” November 2016

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 (October 2016). Highlights that may be of interest to LaborCare® network providers include:

  • Revision to multiple procedure payment reduction for diagnostic cardiovascular procedures — now effective
  • Reminder on new Evaluation and Management Reimbursement Policy — now effective
  • New specialty medications to require prior authorization — scheduled for January 2017
  • Gender dysphoria treatment to require prior authorization — scheduled for January 2017
  • New policy on National Drug Code (NDC) requirement — scheduled for January 2017
  • Reminder that “UHC Link” online tool allows providers to verify eligibility and benefits, check claim status, and submit claim reconsideration requests

View the October 2016 UHC provider bulletin.

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Posted: October 26, 2016

Date: 9/27/2021 8:18:06 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01