February 2017
General News
Medica Foundation announces provider grant recipients
2016 behavioral health grants total $360,000
In 2016, the Medica Foundation awarded behavioral health program grants totaling $360,000 to nine nonprofit agencies. Program grants were awarded to the following provider groups and health care foundations:
- Catholic Charities of Saint Paul & Minneapolis (Minneapolis) – to meet the needs of homeless adults being released from hospitals by dedicating medical respite beds and a full-time mental health provider for their care
- North Metro Pediatrics (Coon Rapids) – to partner with Lutheran Social Services to offer trauma-focused counseling to uninsured children in northern Twin Cities communities
- Hazelden Betty Ford Foundation (Center City) – to place a counselor on the campus of Northeast Metro Intermediate School District 916 to provide chemical health education and prevention services
This cycle of grant-making focused on programs that help people with serious mental illness and addictions recover and lead productive lives in their communities.
Details about grant recipients, funding opportunities, giving guidelines and application deadlines are available online at medicafoundation.org. Information on Medica Foundation funding priorities and grant application periods for 2017 is expected to be available in March 2017.
Effective December 31, 2016:
Preferred Integrated Network pilot program has ended
The Preferred Integrated Network (PIN) pilot program, available to eligible Special Needs Basic Care (SNBC) members residing in Dakota County, has ended as of December 31, 2016. The mutual decision to discontinue this pilot program involved the Minnesota Department of Human Services (DHS) and PIN program leadership. The SNBC PIN pilot program supported enrolled members in Dakota County by blending physical and mental health case management and care coordination for SNBC-enrolled adults with serious mental illness. The goal of the program was to improve and coordinate physical and mental health and social services.
The pilot dates back to 2009, when PIN was formed from a public-private partnership among Medica, Medica Behavioral Health and Dakota County. The program was awarded a DHS Commissioners Circle of Excellence Award in 2012 and was also awarded a State Innovation Model (SIM) grant in 2015 to explore e-health opportunities.
Despite the program’s end, partners in PIN learned the importance of a more comprehensive and holistic role for case managers and care coordinators serving enrollees experiencing serious mental illness, as well as the value of integrating behavioral services, social services and community supports. These learnings will help in future work being done at Medica as well as the state level.
As of November 2016, there were fewer than 350 members enrolled in the PIN pilot program. All members were sent notices by the state as part of the annual health plan selection process and given the option to stay enrolled in Medica AccessAbility Solution®, the Medica SNBC product, or choose to enroll with another managed care plan offering the SNBC program in Dakota County. Many PIN members chose to remain with the Medica SNBC product and their transition from the PIN pilot has been seamless.
Claims for services received during the PIN program must adhere to timely filing guidelines and guidance from DHS. All original claims must be received by Medica no more than 180 days after the date of service or date of discharge for inpatient claims. In addition, DHS advises that all PIN-related claims activity --- from original submissions to resubmissions to adjustments --- must be submitted for payment on or before December 31, 2017.
Reminder on COB for Medicaid claims
Based on Minnesota state law:
- Medicaid is always the payer of last resort when a Minnesota Health Care Programs (MHCP) member has other coverage; and
- For eligible services provided to MHCP members, Medica coordinates benefits and reimburses providers up to the Medica Medicaid fee schedule amount.
Medica requires coordination of benefits (COB) details to process MHCP claims correctly and prefers that these details are submitted electronically. Electronic submission would save providers time and eliminate the need for copies of other payers’ documentation such as an explanation of benefits (EOB), an Explanation of Medicare Benefits (EOMB) or a provider remittance advice (PRA).
At a minimum, in order to pay claims correctly, Medica needs: the amount paid by the primary payer; the total non-covered amount; and the remaining patient liability. Providers that do not have the ability to send such details with their electronic submission should continue to send a paper copy of the EOB or PRA as required for claims payment.
To submit secondary/COB claim details electronically to Medica, providers can refer to their electronic data interchange (EDI) vendor’s 837p/837i implementation guide, or refer to the Health Insurance Portability and Accountability Act (HIPAA) Companion Guide for eCOB specifications.
Effective April 30, 2017:
Medica withdraws from Minnesota PMAP, MinnesotaCare programs
Medica has given the State of Minnesota notice that it will withdraw from the Minnesota Families and Children Medicaid program. This change will specifically apply to populations enrolled in Medica products for MinnesotaCare and Medical Assistance (MA), also known as Prepaid Medical Assistance Plan (PMAP). This termination will be effective April 30, 2017. As a result, coverage for more than 300,000 Minnesota families and children will change effective May 1, 2017.
Based on terms of regulatory requirements for providers related to state government programs, Medica is terminating the portion of provider contract and related requirements pertaining to Medica’s management of MinnesotaCare and Minnesota MA programs. This change will be effective with the April 30 date of termination of Medica’s contract with the Minnesota Department of Human Services (DHS). As a result, for services provided to these members, claims with dates of service on or after May 1, 2017, will no longer be paid by Medica. For services through April 30, providers can continue to submit claims to Medica for payment. Standard timely filing and appeals timelines will apply to claims for services provided to Medica’s MinnesotaCare and PMAP membership, including the standard claims runout period of 18 months beyond April 30, 2017. Medica will also be responsible for inpatient hospital claims for these members beyond April 30 if they are admitted prior to that.
The state enrollees affected by this change will be a majority of Medica Choice CareSM members and all Medica MinnesotaCare members. Medica Choice Care members enrolled in the Minnesota Senior Care Plus (MSC+) program are not affected, and neither are Medica members in the state’s Minnesota Senior Health Options (MSHO) and Special Needs Basic Care (SNBC) programs. These latter enrollees are Medica DUAL Solution® and Medica AccessAbility Solution® members.
After negotiating the reimbursement it receives from DHS, Medica determined that its proposed rates from the state meant losses in Medicaid reimbursement would reach unprecedented levels and put the ability to serve all Medica members at risk. Medica had hoped to work with the state toward a solution that addresses the needs of Minnesota taxpayers, DHS, insurers and, most of all, the children and families covered through this program.
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Clinical News
Effective April 1, 2017:
Medica to implement new coverage policy
The following benefit determination will be effective beginning with April 1, 2017, 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.
Carotid intima-media thickness measurement
Medica has reviewed carotid intima-media thickness (CIMT) measurement and determined that this technology is investigative and therefore will not be covered. CIMT measurement is used for screening, diagnosis, and/or management of atherosclerotic disease.
CIMT measurement is a non-invasive test that measures the lining of the carotid (neck) arteries. The intima is the innermost layer of the artery and the media is the middle layer of the artery. CIMT is typically measured using B-mode ultrasound (US), an imaging method that uses high-frequency sound waves to produce images of structures within the body. B-mode US produces 2-dimensional images of the walls of the carotid artery, which are then analyzed by computer software. Because several studies have identified an association between CIMT and cardiovascular disease (CVD), CIMT has been proposed as an objective measurement capable of detecting CVD before symptoms appear. This has also led researchers to theorize that it may be used to predict risk of heart attack and stroke, independent of traditional risk factors, such as age, sex, high blood pressure, diabetes and smoking. However, more study is needed.
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 April 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 April 1, 2017:
Medica to make UM policy change
Medica will soon revise the following utilization management (UM) policy that requires prior authorization, effective beginning with April 1, 2017, dates of service. This change will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Varicose vein and venous insufficiency treatments
Medica has reviewed mechanochemical ablation (MOCA) for the treatment of varicose veins (ClariVein®) and has determined that this technology is investigative and therefore will not be covered.
Endovenous MOCA is an ablation technique that combines mechanical ablation with the use of a sclerosing agent to close veins. MOCA is a nonthermal technique for the treatment of varicose veins that combines endomechanical abrasion via the tip of a rotating catheter wire with chemical ablation delivered by injecting a sclerosant over the rotating wire. This technique induces clotting, resulting in the occlusion of the diseased vessel.
The complete text of the policy that applies to the determination above will be available online or on hard copy:
- See Medica’s UM policies as of April 1, 2017; or
- Call the Medica Provider Literature Request Line for printed copies of documents.
Effective April 1, 2017:
Medica 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 April 1, 2017, unless otherwise noted.
UM policies — Revised
These versions will replace all previous versions.
| Name |
Policy number |
| Varicose Vein and Venous Insufficiency Treatments |
III-SUR.26 |
Coverage policies — New
| Name |
| Carotid Intima-Media Thickness Measurement |
Coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Serological Markers for Diagnosis and Management of Inflammatory Bowel Disease (IBD) or Irritable Bowel Syndrome (IBS) |
| VeriStrat® Proteomic Testing |
These documents will be available online or on hard copy:
The importance of prenatal and postpartum care
It is recommended that women who are pregnant see their doctor as soon as they are pregnant, but at least by the sixth week of pregnancy. Regular visits after that point allow the health care provider to assess the physical and psychosocial well-being of the mother. When a patient doesn’t engage in prenatal care, the baby is three times more likely to have a low birth weight.
Prenatal care
Women with no risk factors should be seen one time a month for the first 4-28 weeks of pregnancy, every two weeks during gestational weeks 28-36, and every week during gestational weeks 36-40. High-risk patients should be seen more frequently, or as determined by their health care provider.
The American College of Obstetricians and Gynecologists (ACOG) recommends that women should at minimum be screened for alcohol use annually, as well as within the first trimester of pregnancy. Alcohol-related mortality is the third-leading cause of preventable death among women in the United States. Alcohol is toxic to fetuses and is associated with growth impairment, fetal abnormalities, central nervous system impairment, behavioral disorders and impaired intellectual development. Risk of alcohol abuse is defined as seven or more drinks per week, three or more drinks per occasion, or any amount of consumption among those who are pregnant or at risk of pregnancy.
The US Preventive Services Task Force (USPSTF) recommends that all pregnant women should be screened for pre-eclampsia by measuring blood pressure at each clinical prenatal visit. Women who are at higher risk should be seen more often.
Risk factors for women include: age 35 years and greater, pre-existing health problems, medical problems developed during pregnancy, and risk of pre-term labor. Previous pregnancies may be an indicator for risk status.
Postpartum care
Postpartum visits after the birth of a child are equally as important as prenatal care. Often this care is fragmented among maternal and pediatric health care providers. Currently, 40 percent of women do not attend a postpartum visit; however, it is recommended that all women undergo a comprehensive postpartum visit within the first 4-6 weeks after birth. This visit should include a full assessment of the physical, social and psychological well-being of the mother. In some cases, health care providers suggest women be seen 3-5 days after delivery.
Early postpartum follow-up is recommended for women with hypertensive disorders of pregnancy and should include a blood pressure evaluation no later than 7-10 days postpartum. Early follow-up is also beneficial for women at a high risk for other complications such as postpartum depression, cesarean or perineal wound infection, lactation difficulties, or a chronic condition such as seizures. It is also important for women who had gestational diabetes or a pre-term birth, as these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.
It is essential that women who experience a miscarriage, still birth or neonatal death also receive follow-up care. The visit can include emotional support, bereavement counseling and a referral, if appropriate.
For more information, refer to USPSTF, ACOG or Medscape.
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Pharmacy News
Effective May 1, 2017:
Medica to update commercial, IFB, MHCP drug lists
Medica has reviewed several medications and will be making changes in coverage status to drug formularies (or drug lists) effective May 1, 2017. These changes will apply to the Medica Commercial Preferred Drug List; the Preferred Drug List for individual and family business (IFB) members and small group plan members; and the Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP). The Medica MHCP formulary applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.
Medica will post changes to its drug formularies on medica.com 60 days prior to their effective date. To see the latest Medica drug list changes as well as full drug formularies for each member type, refer to medica.com.
As a reminder, Medica has fully transitioned to CVS Caremark as its pharmacy benefit manager (PBM) effective January 1, 2017. Providers will need to work with CVS Caremark to request prior authorization and formulary exceptions under the pharmacy benefit for all Medica members.
Medication request forms
A formulary exception 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 submit an exception form or call CVS Caremark.
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Network News
Effective April 1, 2017:
Medica to update Medicare physician fee schedule
Beginning with April 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 reflect the April 2017 Centers for Medicare and Medicaid Services (CMS) update applicable to reimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided. Updates for durable medical equipment (DME) and orthotics and prosthetics (O&P) will not be implemented at this time.
Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.
Third-quarter PCR checks to be mailed in January 2017
By the end of January 2017, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the third quarter of 2016. This represents a 100-percent return of the third-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 July 1, 2016, through September 30, 2016, and dates paid of July 1, 2016, through December 31, 2016.
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Administrative News
For claim validation review, secure reply options available
Medica will soon implement a new program for claim validation review that will be applied for several types of claims, as previously announced. This new “payment integrity” process will be administered by SCIO Health Analytics®, and is intended to reduce billing errors, as required by the Centers for Medicare and Medicaid Services (CMS).
SCIO Health Analytics will send out medical record requests to providers beginning in February 2017. Providers will have several options to reply when they receive requests for supporting documentation, such as sending it securely by fax or file transfer protocol (FTP), or mailing it on a compact disc (CD). Here are a few details on reply options that may be helpful.
FTP site: Providers can electronically upload medical records through a secure FTP site. For set-up, providers can e-mail [email protected] to request a folder and password. Then, providers should ensure that medical records are in the correct order, as requested.
Encrypted CD: Providers can mail an encrypted CD to the address below for express mail, if using FedEx or UPS (or mail it to the mailing address provided by SCIO Health Analytics). Providers should ensure that medical records are in the correct order, as requested. And as a follow-up, providers will need to send an e-mail to [email protected] with the password for the secure CD.
Express mail:
Attn: Audit Coordination
SCIO Health Analytics
111 Ryan Court, Suite 300
Pittsburgh, PA 15205
Providers can also use the secure fax number or appropriate U.S. mail address as directed by SCIO Health Analytics when they reach out for records. These reply options vary by claim type.
As a reminder, 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.
(Update to "Claim validation review to start in early 2017" article in the January 2017 edition of Medica Connections.)
Effective January 1, 2017:
Medica revises reimbursement policies
Medica recently updated the reimbursement policies indicated below, effective with January 1, 2017, dates of processing, unless otherwise noted. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replaced all previous versions.
| Name |
| Ambulance (updated code list) |
| One or More Sessions (updated code list) |
| Same Day Same Service (updated code list) |
| Supply (updated code lists) |
Reimbursement policies — Retired
| Name |
| Moderate Sedation (retired 12/31/16) |
The revised policies are 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 |
| Will update requirements for inpatient hospital interim billing (as previously published) |
“Billing and Reimbursement” section, in “Claim Submission Requirements for Facilities” subsection |
January 2017
(effective 2/1/17) |
For the current version, providers may view the Medica Provider Administrative Manual online.
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SelectCare/LaborCare News
Effective April 1, 2017:
WPS to apply its policies, code edits to SelectCare claims
Effective with April 1, 2017, dates of processing, WPS Health Solutions will begin applying its own policies and code edits to Medica SelectCareSM claims. WPS is a third-party administrator (TPA) for SelectCare. Patients who access the SelectCare network can easily be identified by the SelectCare logo on their member ID cards, including those for WPS enrollees.
Providers can access WPS policies and code edits through the recently updated WPS website, where additional provider-focused content is now available including reimbursement policies, medical policies, a provider manual and a secure provider portal. Through the WPS provider portal, providers can access member eligibility, benefit information, claim information, a Code Combination Simulation Tool, and medical policy updates. Refer to the WPS website.
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (January 2017). Highlights that may be of interest to LaborCare® network providers include:
- 2017 UHC Provider Administrative Guide now available online
- Claims for E/M services may be subject to review – effective as of January 2017
- For HRA payments, ERAs to include new remark codes – scheduled for February 2017
- Prior authorization for foot surgery – delayed until April 2017
- Some treatment of gender dysphoria to require prior authorization – scheduled for April 2017
View the January 2017 UHC provider bulletin.
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