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Provider Medica Connections


June 2017

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


General News

Medica to make updates to Premium program for 2017

Medica is making several updates to the Premium Designation program for the 2017 program year. Through the Premium program, individual physicians receive designations based on quality of care and cost efficiency.

The most significant program change for 2017 will be with program administration: UnitedHealthcare will begin administering all activities of the Premium program on Medica's behalf starting this summer. A new feature will also be available starting this year: Physicians will be able to delegate the handling of their Premium program activities to a staff member, including the review of patient-specific reports online.

Physicians included in the Premium program this year will receive a mailing in July announcing their new designation as well as outlining Premium program changes for 2017. The new Premium designations will be displayed online in the fall, tentatively scheduled for September 2017. The Medica provider-search tool on will be updated to reflect the new designations.

As a reminder, Medica made other Premium program changes at the end of March 2017. This included new heart icons representing designations, and a display of "Premium Care Physician" (rather than "Tier 1") as the new top rating for physicians who provide high-quality and cost-efficient care.

Annual notice:
Provider appeals on behalf of Medica members

Medica members have the right to appoint representatives, such as their providers, to initiate member appeals. For cases involving member liability, providers may initiate an appeal on behalf of a Medica member by calling the Medica Provider Service Center. At the request of the member or provider, the appeals staff will conduct a case review of previously denied services to ensure accurate review, and coverage of eligible services according to the member's benefit document.

For more details about appeals:

  • See Benefit Appeals in the Provider Administrative Manual.
  • See Member Assistance Services in the Provider Administrative Manual.

Annual notice:
Member rights and responsibilities, for providers to know

Medica recognizes the importance of a three-way relationship among members, their providers and their health plan. Medica believes that educating members about their healthcare responsibilities is important because it helps members get the greatest benefit from their health plan. Medica outlines member rights and responsibilities for the Medica physician and provider community in order to improve the health of the members Medica serves.

As a reminder, information about member rights and responsibilities is posted online. Providers are encouraged to review and understand these details. View Regulatory/Reporting Information in the Medica Provider Administrative Manual.

Annual notice:
Medica reaffirms its policy regarding utilization management

Utilization management (UM) is a process Medica uses to evaluate healthcare services for appropriateness and efficacy. Medica UM decisions are based on national and local standards that support the provision of evidence-based care. All decisions also incorporate a member's benefits and Medica coverage policies. Medica does not specifically reward providers, practitioners, staff members or their supervisors who conduct utilization reviews on the behalf of Medica for issuing denials of coverage or service. It is important to note that UM decision-makers do not receive financial incentives from Medica as a means of encouraging them to make decisions that result in the underutilization of services.

Providers who want more information about the UM process may refer to Medica UM policies at

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Clinical News

Effective July 17, 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. These policies will be effective July 17, 2017, unless otherwise noted.

As previously published, monthly updates to Medica's policies will be available on an ongoing basis. Updates will be posted on prior to their effective date. The medical policy changes effective July 17, 2017, are already posted, and upcoming changes effective August 21, 2017, will be posted in June 2017. Policy changes are expected to be effective as of these dates unless otherwise noted.

The medical policies themselves will be available online or on hard copy:

Effective August 1, 2017:
Medical policies and clinical guidelines to be updated

In addition to the upcoming policy changes noted above, 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 August 1, 2017, unless otherwise noted.

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

Name Policy number
Adult Gender Reassignment Surgery III-SUR.20
Bone Growth Stimulators III-DEV.07
Microprocessor Controlled Knee Prostheses, with or without Polycentric, Three-Dimensional Endoskeletal Hip Joint System III-DEV.17
Outpatient Enteral Nutrition Therapy III-MED.03
Real-Time Mobile Cardiac Outpatient Telemetry (RT-MCOT) III-DIA.08

These documents will be available online or on hard copy: 

The importance of well-child and teen checkups

A child's early years of life are very important for optimal health and development. Healthy development means that children of all abilities are able to grow up where their social, emotional and educational needs are met.

The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is a federal program required in every state to provide quality well-child care for children eligible for Medicaid. EPSDT stresses the following activities:

  • Early: Assess and identify problems early
  • Periodic: Check children’s’ health at periodic, age-appropriate intervals
  • Screening: Provide physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
  • Diagnosis: Perform diagnostic tests to follow up when a risk is identified
  • Treatment: Control, correct or reduce health problems

Newborns, children and adolescents through 20 years of age should get routine child and teen checkups (C&TCs). This helps to ensure health problems are screened for, diagnosed and treated early, before they become more complex and costly. The U.S. Centers for Medicare and Medicaid Services (CMS) has set a goal for states to have an 80 percent participation rate in C&TC screening services during the reporting year.

Providers can avoid fragmentation of care and help reduce duplication of services by substituting a C&TC service, when appropriate, for other preventive health care visits, such as: newborn and well-baby checkups; school, camp or athletic physicals; Head Start physicals; immunizations; or early childhood screenings.

The C&TC medical screening components include the following: physical growth and measurement, health history, developmental history and screening, physical exam, immunizations, laboratory tests, newborn screening follow-up, vision and hearing screening, age-appropriate fluoride varnish application, referral to a dental provider, maternal depression screening, autism spectrum disorder screening, social-emotional or mental health screening, substance abuse assessment and anticipatory guidance.

Children reach milestones in how they play, learn, speak, behave and move (for example, crawling and walking). The developmental milestones give a general idea of the changes to expect as a child gets older. A developmental screening will tell if a child is learning the basic skills that they should, or if they might have delays. Screening for social, emotional and developmental concerns is essential to early identification of mental health problems in children and youth. Screening provides an opportunity to intervene early and improve the course of healthy development and functioning. Earlier identification means earlier intervention to treat depression or other conditions, preventing problems from becoming more severe and saving lives.

Health education and anticipatory guidance given to both parents or guardians and children is required and designed to assist in understanding what to expect in terms of the child’s development, and to provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention.

In related news: Due to the recent measles outbreak, the Minnesota Department of Health (MDH) has released an updated guideline on vaccinating children for measles.

In addition, the American Academy of Pediatrics (AAP) has come out with the following recommendations for children's media use.

Age of child Time using media
Younger than 18 months Only use for video-chatting
18 to 24 months High-quality programs and parents should watch with child
2 to 5 years One hour per day of high-quality programs — parents should co-view with child
6 years and older Consistent limits on time spent using media and types of media. Important to ensure that media does not take the place of adequate sleep, physical activity and other behaviors essential to good health.
Other recommendations
  • Designate media-free times together, such as dinner or driving
  • Media-free locations at home, such as bedrooms
  • Ongoing conversation about online citizenship and safety, including treating others with respect online and offline

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Pharmacy News

Effective July 1, 2017:
Medica outlines upcoming changes to drug lists

As noted last month, Medica will be making changes in coverage status to member drug formularies (drug lists) effective July 1, 2017. For certain Medica members, as noted below, these changes would be effective July 1, 2017, for new prescriptions, but not effective until August 1, 2017, for existing prescriptions. The changes to these formularies are now posted online.

  • See changes to the 2017 Medica Commercial Large Group Drug List - effective 7/1 for new prescriptions, 8/1 for existing prescriptions.
  • See changes to the 2017 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP) - effective 7/1 for new prescriptions, 8/1 for existing prescriptions.
  • See changes to the 2017 Medica Commercial Small Group Drug List.
  • See changes to the 2017 Medica Preferred Drug List for individual and family business (IFB)

Effective August 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 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 August 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.

Effective August 1, 2017:
Medica to add new UM policies for medical pharmacy drugs

Medica will soon implement the following new medical pharmacy drug utilization management (UM) policies. These changes will be effective with August 1, 2017, dates of service, unless otherwise noted. Prior authorization will be required for the corresponding medical pharmacy drugs. These UM changes will apply to relevant prior authorization and pre-payment claims edit policies.

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

Drug code Drug brand name Drug generic name
J3590 Brineura cerliponase alfa 
J9999 Imfinzi durvalumab
J3490 Radicava edaravone

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:

List coming soon for new-to-market medical benefit drugs

As previously announced, Medica is implementing a process to review and determine appropriate coverage or utilization management (UM) drug policies for medical benefit drugs and biologics that are new to market. As part of this process, to assist providers in determining coverage for a patient, Medica will make a list available of new-to-market medical benefit drugs recently approved by the U.S. Food and Drug Administration (FDA). As of June 1, 2017, this list will be posted on the Drug Management Policies webpage under the New-to-Market Medical Pharmacy Products coverage policy. The list will include medical pharmacy products currently under clinical review by Medica for a coverage determination.

As a reminder, Medica's New-to-Market Medical Pharmacy Products coverage policy states that all new-to-market medical pharmacy products are not covered until completion of a review process by Medica. This new drug coverage policy is available online and will be effective June 1, 2017.

"New to market" means up to six months from the date of final FDA approval. Medica will conduct its clinical review for each new medical pharmacy product within six months of that FDA approval, including a review of clinical data and patient safety information, and then make a coverage determination.

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Administrative News

Provider College administrative training topic for June

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
"Life of a claim" (class code: LC)
This class translates the life of a claim into three components: submission policies, process and output. Participants will review Medica submission policies for claims, then learn how Medica processes a claim and examine what information is produced when a claim has finished processing. Submission requirements will be identified for CMS-1500 and UB-04 claim forms as well as 837P and 837I electronic transactions, including information on national provider identifier (NPI) numbers. Participants will learn about the referral workflow process, provider remittance advices (PRAs), and claim adjustments and appeals. This class will also cover details on timely-filing timeframes as well as claims-processing platforms used by Medica, including the platform used for individual and family business (IFB).

Class schedule
Class code  Topic Date Time
LC-WJun Life of a Claim June 6 10-11:30 am Class code with "WJun" means offered via webinar in June

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 January 1, 2017:
Medica revises reimbursement policy

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

Multiple Procedures (updated code lists)

This revised policy is available online or on hard copy:

Updates to SelectCare/LaborCare 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's SelectCare/LaborCare Provider Administrative Manual. Every effort is made to keep the manual as current as possible for Medica SelectCare℠ and LaborCare®. The table below highlights updated information and when the updates were (or will be) posted online in this administrative manual.

Information updated Location in manual When posted
Added information regarding third-party administrators (TPAs) applying their policies or code edits to SelectCare or LaborCare claims Under Administrative Manuals, an additional note under "SelectCare and LaborCare" May 2017

For the current version, providers may view provider administrative manuals 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 (May 2017). Highlights that may be of interest to LaborCare® network providers include:

  • Revisions to Evaluation and Management Policy — now effective (updated timing)
  • Prior authorization requirements for molecular and genetic testing — scheduled for third quarter 2017
  • Revision to Add-On Policy — scheduled for August 2017
  • Revision to Procedure and Place of Service Policy — scheduled for August 2017

View the May 2017 UHC provider bulletin

Effective July 24, 2017:
UMR to apply its policies, code edits to certain claims

Effective with July 24, 2017, dates of processing, UMR will begin applying its own policies and code edits to Medica SelectCare℠ facility claims. UMR 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 UMR enrollees.

Providers can soon access UMR policies and code edits through the recently updated UMR website, where additional provider-focused content is now available including reimbursement policies, medical policies, a provider manual and a secure provider portal. Through the UMR provider portal, providers can access member eligibility, benefit information, claim information, a Code Combination Simulation Tool, and medical policy updates. Refer to

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Posted: May 24, 2017

Date: 10/25/2021 10:07:40 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01