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Provider Medica Connections

September 2017

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

General News

Annual notice:
Medica encourages its members to get flu shots

Each year, Medica encourages its members to get seasonal influenza shots, and will do so again by promoting them through member newsletters, worksite flu-shot clinics and targeted member mailings this fall. Members are highly encouraged to discuss with their health care professional which vaccine is appropriate for them.

Vaccine priorities 
The U.S. Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommend that everyone 6 months of age and older get a flu vaccine each year. It is especially important for the following individuals to receive a flu vaccine, either because they are at higher risk for infections or complications from the flu, or they live with or care for those at higher risk:

  • Pregnant women
  • Household contacts and out-of-home caregivers of children younger than 5 years of age, but especially children younger than 2 years of age
  • People 50 years of age and older
  • People of any age with certain chronic medical conditions
  • People who live in nursing homes and other long-term-care facilities
  • People who live with or care for those at high risk for complications from flu, including health care workers
  • Household contacts of persons at high risk for complications from the flu

Pharmacist-administered vaccination
Medica members may be able to receive their flu vaccination through a Medica network pharmacy. Inquiries can be directed to a member's local pharmacy.

Billing for shots
Clinics should use their regular billing methods for flu shots. To ensure full coverage, Medica members must receive shots from a Medica network provider.

When submitting claims for flu shots, providers should use applicable codes of the International Classification of Diseases (ICD-10-CM), Common Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS). Medica will accept codes for reimbursement as outlined by CDC.

More information
More on seasonal flu vaccine is available online:

Providers who have questions or comments about Medica flu and pneumonia prevention programs may call the Medica Provider Service Center at 1-800-458-5512. In the event of a vaccine shortage, providers are encouraged to refer to the Minnesota Department of Health (MDH) website.

Medica to update cost information for consumers

Medica will soon update cost information on its Main Street Medica website for consumers. Information will be updated for clinic conditions, durable medical equipment (DME), radiology and inpatient and outpatient procedures. This update will occur in mid-October 2017.

Main Street Medica includes a variety of information to help members make informed choices about their health care. As part of the update process, Medica conducts a review of recent claims to determine the conditions, diseases and procedures to be included. These services are then analyzed to determine the cost information based on current contracts for the Medica Choice® Passport provider network. Results are displayed for organizations using average cost ranges.

Providers who have any questions about the information on Main Street Medica, or would like to receive a copy of a report for their organization, may contact their contract manager.

PCA administrative guide updated

Medica has recently updated and posted its administrative requirements guide for personal care assistance (PCA) providers and agencies. Here are some of the changes:

  • The “Vulnerable Child and Adult Maltreatment” section has been updated to include children as well as where to report.
  • The "Employee Oversight" section has been updated to include language on service verification calls
  • The live links throughout the document have been updated to provide helpful resources.
  • Forms have been removed if no longer needed or replaced with a current version.

See the current Medica PCA guide. 

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Clinical News

Effective October 16, 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 October 16, 2017, unless otherwise noted.

Monthly updates to Medica's policies are available on an ongoing basis. Updates are posted on prior to their effective date. The medical policy changes effective October 16, 2017, are already posted, and upcoming changes effective November 20, 2017, will be posted in September 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:

Caring for senior patients' health

The U.S. Preventive Services Task Force recommends preventive screenings for seniors (those 65 years of age and older) on an annual basis. Seniors’ health problems increase with age and keeping up with the preventive services can help keep them healthy and active.

For both men and women who are seniors, it is recommended they have their cholesterol, blood pressure and body mass index checked each year. Screening for alcohol abuse and dementia should also be addressed annually. Depression screening should be done routinely, and any time the patient is in the office.

Annually, immunizations for both men and women should include influenza. Frequency of the pneumococcal vaccine should be discussed based on the patient’s health status. Other immunizations include tetanus/diphtheria/acellular pertussis (Td/Tdap). Tdap should be administered at least once, and Td should be offered every 10 years. Zoster is another recommended immunization for the prevention of shingles and should be given as a single dose to patients after they are 60 years of age.

Men 65-75 years of age should receive one lifetime screening for abdominal aortic aneurysm if they are at risk. Women seniors should receive a mammography screen annually and osteoporosis (bone mass density) screening annually. A bone mass density screening should be done within 180 days after a fracture occurs in a female patient.

Other important health topics to discuss with senior patients include:

  • Adhering to medication or therapies, including prescribed medications and supplements
  • Creating/maintaining an advance directive
  • Safety
  • Eating properly
  • Exercising
  • Managing daily living and activities

A study led by an economist in 2015 reported that health care spending for American seniors was approximately $18,624 per person per year. These costs are covered by Medicare, Medicaid, private insurance and patient out-of-pocket expenses (about 20%). Nursing home costs accounted for a large portion of out-of-pocket and Medicaid expenses. Keeping seniors healthy can help manage and reduce health care expenses for everyone.

Medica reminds members to get needed preventive care services

To help members manage their health, Medica will be reminding them to get preventive health services that are overdue. The recommendations will be sent in a personalized letter targeting Medica Medicare members and some commercial group members, to arrive in member mailboxes this fall, likely in September 2017. Services will be based on routine care health guidelines aligned with the U.S. Preventive Services Task Force (USPSTF). For optimal health, the hope is that these members schedule and complete any incomplete services as quickly as possible. They will be encouraged to take their reminder letter to their scheduled appointment with a health care provider.

For the fall mailing, information used to identify incomplete preventive care will be based on the most recent claims records that Medica has on file. Medica may not have a record of the service for members who completed a service in the 90 days prior to receiving the letter, or who are new to Medica or who have completed a service prior to becoming a Medica member.

Note: Members will be notified about certain services, as not all preventive care services will be identified for all members included. The letter will serve as a guide yet is not intended to replace the care and recommendations of health care providers.

Medical experts understand the value of preventive care in the form of immunizations and screenings. By encouraging patients to obtain recommended routine care, providers and patients are able to identify potential health concerns early or avoid them altogether. This may be one of the best ways to help patients learn about a health issue that can be caught early and managed well.

Medica realizes that it may not always be clear to members which routine care they or their family need. Despite supportive guidance from a health care professional, sometimes patients simply need a reminder.


Survey coming!
Providers can soon give input on Medica UM services

In order to improve service to providers and members, Medica periodically surveys network providers about satisfaction with certain programs offered by the health plan. Medica will soon send providers a survey about utilization management (UM) services, including prior authorization requests. Providers will be able to give their feedback on UM until September 22, 2017. Survey responses are confidential and grouped with other results. Those who are signed up to receive Medica Connections can look for the survey coming electronically by early September.

This UM survey is valuable for continual process improvement at Medica. Based on previous surveys, Medica has updated its processes, such as refining prior authorization request forms and UM policies and making them easily accessible at

For more about UM surveys, providers may contact Sharon Chambers, senior director of clinical operations, at or 952-992-2205.

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Pharmacy News

Effective October 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 October 1, 2017. For certain Medica members, as noted below, these changes would be effective October 1, 2017, for new prescriptions, but not effective until November 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 10/1 for new prescriptions, 11/1 for existing prescriptions (except for specialty drug quantity limit changes to be effective 10/1 for both new and existing users).
  • 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).
  • See changes to the 2017 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP) - effective 10/1 for new prescriptions, 11/1 for existing prescriptions.


Effective September 1, 2017:
Medica to revise UM policy for medical pharmacy drug

Medica will soon revise the following medical pharmacy drug utilization management (UM) policy, effective with October 1, 2017, dates of service. The following policy is being updated to reflect a new formulation of rituximab. This UM change will apply to relevant prior authorization and pre-payment claims edit policies.

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

Drug code Drug brand name Drug generic name  Change
J9310/J9999 Rituxan/Rituxan Hycela  rituximab  Addition of Rituxan Hycela to existing Rituxan policy

This policy applies to Medica commercial, Minnesota Health Care Programs (MHCP) and individual and family business (IFB) members, but not to Medica Medicare members. The policy is subject to pre-payment claims edits as well.

This revised medical pharmacy drug UM policy will be available online or on hard copy:


Effective November 1, 2017:
Medica to make ACA coverage changes for statin medications 

Effective November 1, 2017, there are mandated changes to the list of required preventive services under the Affordable Care Act (ACA). As a result of this change, Medica will add low- to moderate-dose statins to its standard coverage recommendation for ACA preventive services. This will be an update to the ACA drug list and applicable to all plans eligible for coverage of these medications, which will apply for Medica's commercial members and individual and family business (IFB) members.

Statins are a class of lipid-lowering medications used to reduce cardiovascular disease and mortality in those who are at high risk. These medications, and all other ACA-mandated preventive services for non-grandfathered plans, will be covered at 100 percent.

The upcoming coverage changes will include:

  • Coverage for men and women 40 to 75 years of age
  • No quantity limit
  • No prior authorization
  • Low- to moderate-dose statins, generic only (no high-dose or brand statins are included)

Here are the drugs and dosage strengths newly added to the ACA drug list:

  • Atorvastatin 10 mg, 20 mg
  • Fluvastatin 20 mg, 40 mg
  • Fluvastatin ER 80 mg
  • Lovastatin 10 mg, 20 mg, 40 mg
  • Pravastatin 10 mg, 20 mg, 40 mg, 80 mg
  • Rosuvastatin 5 mg, 10 mg
  • Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

For statin prescriptions outside these age ranges or strengths, standard member plan benefits will continue to apply. For reference, see the statin recommendation from the United States Preventive Services Task Force (USPSTF), as published last fall. The USPSTF statin recommendation is effective for plan years beginning on or after November 13, 2017, although Medica will update its standard coverage early to best serve its members starting November 1, 2017.

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Administrative News

Provider College administrative training topics for September

The Medica Provider College offers educational sessions on various administrative topics. The following classes are available by webinar for all Medica network providers, at no charge.

Training class topic
"DME Specialized Claims Training" (class code: DME)
This course will review information to assist providers in submitting claims for durable medical equipment (DME). The training will cover topics such as billing requirements; rental vs. purchase; and codes and modifiers to bill for DME. This session will provide an opportunity for providers to understand how Medica processes DME claims and to learn claim-submission requirements.

"Resources for Helping Yourself" (class code: RH)
Medica is continually updating services and resources available to network providers. This webinar will walk through self-service options available to providers, including resources on These services and resources assist providers in running their offices more efficiently.

Class schedule

Class code Topic Date Time Notes
DME-WS  DME Specialized Claims Training  Sept. 12 10-11 am Class code with "WS" means offered via webinar in September
 RH-WS  Resources for Helping Yourself  Sept. 26  10- 11 am  Class code with "WS" means offered via webinar in September

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 times reflected above allow for questions and group discussion. Session times may vary based on the number of participants and depth of group involvement.

The registration deadlines are one week prior to the class dates. Register online for a session above.

Effective November 1, 2017:
Medica to revise reimbursement policies

Medica will soon update the reimbursement policies indicated below, effective on or after November 1, 2017, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.

Professional/technical components, and laboratory services
Medica will revise the “Professional and Technical Component Policy” and “Laboratory Services Policy” with a change to the facility place of service (POS) codes. Facility POS 55 (for residential substance abuse treatment facility) and POS 57 (for non-residential substance abuse treatment facility) will be added as non-reimbursable POS locations in the Professional and Technical Component Policy when billed with a Current Procedural Terminology (CPT®) code that has a PC/TC indicator of 1 (appending modifier TC), 4 or 5. For the “Laboratory Services Policy,” facility POS 55 and 57 will be non-reimbursable when submitted with a CPT code that has a PC/TC indicator of 3 or 9.

This change will apply to all Medica commercial, Medicare, individual and family business (IFB) and Minnesota Health Care Programs (MHCP) products. 

These revised policies will be available online or on hard copy:

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SelectCare/LaborCare News

Latest UHC provider bulletin available online

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

  • website to replace
  • New prior authorization and notification app on Link — coming soon
  • New pharmacy app gives real-time prescription coverage
  • BioScrip leaving specialty pharmacy network —scheduled for October 2017
  • New prior authorization requirement for outpatient genetic and molecular testing — scheduled for November 2017

View the August 2017 UHC provider bulletin.

Pipe Trades claims run-out extended through January 2018

Medica previously published that Pipe Trades Services MN is terminating its third-party administrator (TPA) contract with LaborCare®, effective August 1, 2017. As an update to the previous notice, however, LaborCare will continue to process claims with dates of service prior to August 1 during a claims run-out period that will extend through January 31, 2018, to accommodate the 180-day timely filing allowance.

(Update to "Pipe Trades union terminates its contract as LaborCare TPA" article in the July 2017 edition of Medica Connections.)

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Posted: August 23, 2017

Date: 9/27/2021 7:39:47 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02