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Provider Medica Connections


April 2017

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


General News

Effective April 1, 2017:
Medica offers new 'VantagePlus with Medica' ACO product

Fairview, HealthEast and North Memorial have collaborated with Medica to create one of the largest accountable care organizations (ACOs) in Minnesota, called “VantagePlus with Medica.” Beginning April 1, 2017, this new ACO product will be available to commercial employer groups in the 13-county Twin Cities metro area. It will be offered through My Plan by Medica℠ or alongside a Medica Choice® Passport plan. See the fact sheet for the new ACO product.

The three provider care systems partnering in this ACO will provide broader geographic access, improvements in service and a greater focus on lowering health care costs. The new ACO will encompass 3,500 primary and specialty care physicians, 650 clinics and 12 hospitals. No referral will be needed to see in-network providers. Members can also access non-network providers but may have higher deductibles and out-of-pocket expenses than for in-network providers.

As a result of this product launch, the current Fairview and North Memorial Vantage and Inspiration Health ACO products with Medica will no longer be available after employer groups transition to VantagePlus over the next year and a half. 

Providers in ACOs collaborate with Medica to make health care more efficient and improve the member experience. The ACO network may be smaller than Medica’s other open-access networks, but the benefits are significant. 

Medica Foundation's final provider grant recipients for 2016
Early childhood health grants total $297,000

In 2016, the Medica Foundation awarded early childhood health program grants totaling $297,000 to 15 nonprofit organizations. Grants were awarded to the following provider groups:

  • Isanti County Public Health Services (Cambridge, Minn.) – to partner with Children’s Dental Services to facilitate the provision of needed dental care for low-income children and families in the community
  • Neighborhood Health Source (Minneapolis) – to implement a registry of pediatric patients with asthma and coordinate care to improve asthma control, medication compliance and screening patients reporting symptoms to reduce emergency room visits and hospitalizations
  • Centro Tyrone Guzman (Minneapolis) – to hire and train a family health specialist to coordinate year-round parent education related to mental health and positive parenting behavior for Latino families 

This cycle of grant-making provided funds to support early intervention programs that focus on healthy families to foster the optimal growth and development of young children. 

Details about grant recipients, funding opportunities, giving guidelines and application deadlines are available online at 

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Clinical News


CME-eligible training focuses on pain, opioids and addiction

As a follow-up to previously published articles about the opioid epidemic, Medica encourages opioid prescribers to sign up for a new online lecture series regarding this topic. The series of 18 seminars is eligible for continuing medical education (CME) credits as well as maintenance of certification (MOC) points for specialty certification in internal medicine, pediatrics and anesthesiology.

The Minnesota Medical Association (MMA), the Steve Rummler Hope Foundation (SRHF) and the University of Minnesota Medical School collaborated to produce the training, bringing medical education on the topic of opioids to medical students, residents and practicing doctors. Underwritten by the SRHF, these lectures were recorded live at the University of Minnesota Medical School. The aim of this training is to create a medical curriculum on pain, opioids and addiction as it should be in a medical school setting, with balanced, practical, evidence-based information free of commercial bias.

“We highly recommend that practicing physicians who see Medica members for pain therapy take this training,” said Mary Braddock, MD, MPH, medical director for health and provider services at Medica. “This lecture series is extensive and would be especially valuable for primary care doctors who prescribe opioids.”

Learn more about this training »

What palliative care is, and its value to patients

Palliative care is medical care that focuses on the prevention and relief of suffering. The foundational goals of palliative care include providing supportive care to achieve the best possible quality of life for patients and their families facing a serious illness. The palliative care team strives to balance the burden of disease and treatment with restoring function. The principles of palliative care include:

  • Treatment and management of pain, symptoms, side effects
  • Establishment of  goals of care to determine priorities for care that inform all care plans
  • Advance care planning
  • Psychosocial support to address depression that is often associated with serious illness
  • Addressing the psychosocial needs of family members and caregivers 
  • Coordination of care with assistance in navigating and understanding the care plan across the health care continuum assisting with specialists, diagnostic, and treatment interventions
  • Medical team conferencing

Patients and families coping with serious illness want and need access to the quality of life that palliative care provides. A 2011 poll revealed that once people were informed about palliative care, 92 percent reported they would be highly likely to consider it for themselves or their families if they had a serious illness. Over the last decade, the medical specialty of palliative care has been one of the fastest-growing trends in health care. Palliative care models exist in a variety of settings. Today, about 75 percent of hospitals with 50 beds or more have a palliative care program where the team provides consultation to the primary attending physician for patients that present with difficult cases.

Making palliative care available to the much larger population of the seriously ill who are receiving care in the community settings where they live, may be the single largest opportunity to improve value in the U.S. health care system. Palliative care services improve patients’ symptoms and the quality-of-life care at any stage of an illness, allow patients to avoid hospitalization and to remain safely and adequately cared for at home, lead to better patient and family satisfaction, and significantly reduce prolonged grief and post traumatic stress disorder among bereaved family members. Palliative care lowers costs by reducing unnecessary hospitalizations, diagnostic and treatment interventions, and avoidable intensive and emergency department care. Among patients hospitalized in intensive care units (ICUs), benefits of early proactive palliative care involvement include earlier and more frequent ICU family meetings and shorter lengths of stay.

The following concepts are ones that all clinicians should understand about palliative care, according to “3 Things All Clinicians Should Know About Palliative Care,” by Debra Beaulieu:

  • Palliative care is not just for the dying. Palliative care is appropriate at any age and at any stage of illness, and can be provided along with curative treatment. About 80 percent of surveyed adults admit they do not know what palliative care means. According to Dr. Sean Morrison, Director of Hertzberg Palliative Care Institute at Mount Sinai Hospital in New York City, "When you ask the same question of physicians, they say they know what it is, but they get it wrong because they equate it with hospice or end of life."

  • Palliative care often occurs too late, if at all. "Right now, access to palliative care depends almost entirely on your treating physician thinking about making the referral," says Dr. Diane Meier, a professor of geriatrics and palliative medicine at the School of Medicine at Mount Sinai in New York. Historically, palliative care has been seen as care provided for people who are dying from their disease. It is now recognized that the principles of palliative care are just as important early on in the course of serious illness, delivered concurrently with treatment. A study with patients who were newly diagnosed with metastatic non-small cell lung cancer showed that early palliative care integrated with standard oncologic care had outcomes associated with a better quality of life, less depressive symptoms, and longer median survival than those who just received oncologic care alone. Patients were also less likely to have chemotherapy continued close to death or to be hospitalized near end of life, and were more likely to enroll in hospice for a longer duration.

  • All clinicians need core palliative care skills. There is a shortage of palliative care services in the U.S. because of limited residency slots in this relatively new field, as well as the aging population of baby boomers. Large-scale training programs are needed to meet a chronic shortage of palliative care specialists and fill a gap by educating the current workforce since these skill sets can benefit anyone involved in patient care.

Effective June 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 June 1, 2017, unless otherwise noted. 

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

Name Policy number
Bone Marrow or Stem Cell (Peripheral or Umbilical Cord Blood) Transplantation III-TRA.01
Heart Transplantation (Adult and Pediatric) III-TRA.12
Heart/Lung Transplantation III-TRA.08
Intestinal Transplantation III-TRA.13
Kidney Transplantation III-TRA.03
Liver Transplantation III-TRA.02
Lung Transplantation (Single or Double) III-TRA.11
Mechanical Circulatory Support Devices III-SUR.38
Pancreas Transplantation (Pancreas Alone) III-TRA.04
Pancreas-Kidney (SPK, PAK) Transplantation III-TRA.05

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

Functional Magnetic Resonance Imaging (fMRI)
Implanted Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (effective 3/15/17; see details )
Scanning Laser Technologies for Retina and Optic Nerve Imaging

ICSI guidelines – Revised
These guidelines are available on

Diagnosis and Initial Treatment of Ischemic Stroke (released in December 2016)
Diagnosis and Management of Asthma (released in December 2016)

These documents will be available online or on hard copy: 

Due by April 15, 2017:
Quality complaint reports required by State of Minnesota

Medica requires its Minnesota-based network providers to submit first-quarter 2017 quality-of-care complaint reports to Medica by April 15, 2017

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


Medica outlines upcoming changes to 2 drug lists

As noted last month, Medica will be making changes in coverage status to two drug formularies (drug lists) effective April 1, 2017, for new prescriptions, and effective May 1, 2017, for existing prescriptions. The changes to these two formularies are now posted online.

  • See changes to the 2017 Medica Commercial Large Group Drug List. 
  • See changes to the 2017 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP).


Effective June 1, 2017:
Upcoming changes to Medica Part D drug formularies

Medica posts changes to its Part D drug formularies on 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 June 1, 2017. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. These latest changes will be posted soon. 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 submit an exception form or call CVS Caremark.

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Administrative News


Provider College administrative training topic for April

The 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
"Medica Prime Solution Medicare Product in ND/SD" (class code: PS)
This course will review information to assist North Dakota and South Dakota providers better understand the Medica Prime Solution® product. Topics include: when Medica follows Centers for Medicare and Medicaid Services (CMS) guidelines; when to bill Medica as primary payer vs. Medicare; upgraded services offered by the plans; billing requirements; and reimbursement. Time will also be provided for questions and answers as part of this discussion.

Class schedule
Class code  Topic Date Time
PS-WApr Prime Solution in ND/SD April 25 10-11 am Class code with "WApr" means offered via webinar in April

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. Register online for the session above.

Effective February 1, 2017:
Medica revises reimbursement policies

Medica has updated the reimbursement policies indicated below, effective on or after February 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.

Bilateral (updated code list )
Assistant Surgeon (updated code list; effective 1/1/17 )
Inappropriate Primary Diagnosis (updated code list; effective 10/1/16 )

These revised policies are 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. 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.

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
Qualified Health Plan (QHP) Addendum updated to include a definition for “Federally-facilitated Exchange” “Special Contracting Requirements” section, in “Qualified Health Plan (QHP) Requirements” subsection February 2017 (effective 6/1/17)
Made regulatory updates to provider non-discrimination requirements for Medicare and Minnesota Health Care Programs; also changed title from "Provider Requirements for Medicare, Medicaid and Government Programs" to "Provider Requirements for Medicare and Minnesota Health Care Programs" "Special Contracting Requirements" section, in "Government Program Requirements" subsection, under "Provider Requirements for Medicare and Minnesota Health Care Programs" March 2017
Made updates to confirm that payments to providers under Medica’s Medicare plans are subject to the federal sequestration-of-payments provisions "Special Contracting Requirements" section, in "Government Program Requirements" subsection, under "Provider Requirements for Medicare and Minnesota Health Care Programs" March 2017

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

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SelectCare/LaborCare News


Effective June 1, 2017:
BPA to apply its policies, code edits to SelectCare claims

Effective with June 1, 2017, dates of processing, Benefit Plan Administrators (BPA) will begin applying its own policies and code edits to Medica SelectCare℠ claims. BPA 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 BPA enrollees.

After logging on to the BPA website, providers can access BPA policies and code edits. Additional provider-focused content is also available through the secure provider portal, including reimbursement policies, medical policies and policy updates. Refer to the BPA website.

Latest UHC provider bulletin available online

UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (March 2017). Highlights that may be of interest to LaborCare® network providers include:

  • Updates to mammography codes — now effective
  • New referral message for eligibility and benefit EDI response transactions — now effective
  • Prior authorization requirement for certain office-based procedures to be covered in other sites of service — scheduled for April 2017
  • Revision to intensity-modulated radiation therapy (IMRT) reimbursement policy — scheduled for June 2017
  • Revision to procedure-to-modifer reimbursement policy — scheduled for June 2017

View the March 2017 UHC provider bulletin

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Posted: March 29, 2017

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