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Provider Medica Connections

October 2017

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

General News

Effective January 1, 2018:
Medica IFB product changes, additions coming to four states

As of January 1, 2018, Medica is making several changes to its individual and family business (IFB) product offering in Minnesota, Nebraska, Kansas and Wisconsin, which will include two new products. As outlined below, open-access networks will be revised for IFB products in Minnesota and Nebraska; the existing service area will be expanded with a new product in Wisconsin; and new products will be added in Nebraska and Kansas. All IFB products will be offered on the federal Marketplace exchange only, except in Nebraska where plans will be available both on and off the exchange.

Here are changes to Medica's IFB products coming to Minnesota, Nebraska and Wisconsin on January 1:

  • The Medica Applause® product will have some significant provider network configuration changes. In addition, Medica Applause will be available statewide in Minnesota only.
  • The previous Medica with Mayo Clinic will become Engage by Medica℠, continuing to offer Mayo Clinic Rochester locations and expanding into two southern Minnesota counties and 14 western Wisconsin counties.
  • The Medica Insure℠ open-access product in Nebraska will offer tiered networks. The tier 1 (preferred) network will include Avera Health, Bryan Health, CHI Health, Great Plains Health, Mary Lanning Health Care, Methodist Health System and UnityPoint Health. The sales area footprint will continue to be statewide in Nebraska.
  • Inspiration Health by HealthEast and Medica℠ will no longer be offered in 2018.

Here are Medica’s new IFB products coming to Nebraska and Kansas on January 1:

  • Medica with CHI Health℠ is a new care-system product for certain counties of Nebraska featuring CHI Health (i.e., Catholic Health Initiatives), also as part of a network through Midlands Choice.
  • Select by Medica℠ is a new care-system product featuring Saint Luke’s in Kansas City, Kansas, as part of an exclusive provider organization (EPO).

Fact sheets for these new and revised products will be available soon at (under Individual and Family Products). 

Health Literacy Partnership campaign promotes plain language

Everyone appreciates simple, clear language when it comes to their health care or health insurance information. And who has the primary responsibility for increasing the use of such plain language? It lies with health care and health insurance professionals and their organizations.

Obtaining health care hinges on having the necessary skills to read, fill out and understand medical and health insurance forms. Consumers also need to communicate with health care providers and follow basic instructions and medical advice. Yet health systems, health care professionals and insurance plans often present information in a way that’s difficult for most people to understand. Resources can be dense, technical and jargon-filled. As a result, the health care system itself can pose a serious barrier to appropriate care!

What’s a simple and effective technique to address this barrier? Using plain language. Plain language is a health literacy tool that allows people to find what they need; understand what they find; and act appropriately on that understanding the first time they hear or read it. To help promote plain language, the Minnesota Health Literacy Partnership has developed a new campaign for health care organizations that includes a business case for plain language, health-related crossword puzzles, “Jargon Alerts” and personalized activities using social media. The campaign is timed to coincide with Health Literacy Month this October, but components of it can be used year-round. See the campaign to promote plain language.

“When people receive accurate, easy-to-understand information about a health issue, they are better able to take action,” said Alisha Ellwood Odhiambo, chair of the Minnesota Health Literacy Partnership. “It’s important to keep the message clear and simple, especially when it’s about our health.”

Provider demographics should reflect actual sites of service

As a reminder, providers should only request that practitioners are set up in health plan demographic data for sites where they are actually practicing, as opposed to all sites under a provider’s tax identification number (TIN). Doing so ensures data accuracy for Medica’s provider directories, including the online provider-search tool at Medica strives to give its members accurate directory details so they can find available providers without frustrations or difficulty, which is in the best interest of providers as well.

To verify demographic data and request updates, providers can use Medica’s secure provider demographic-update online tool (PDOT) or refer to Medica’s website for more information, including the Minnesota Uniform Practitioner Change Form.

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Clinical News

Effective November 20, 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. These policies will be effective November 20, 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 update for medical policy changes effective November 20, 2017, is already posted, and the update for upcoming policy changes effective December 18, 2017, will be posted in October 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:


The impact and treatment of arthritis

According to the Centers for Disease Control and Prevention (CDC), arthritis includes more than 100 rheumatic diseases and conditions that affect joints, the tissues that surround joints, and other connective tissue. The pattern, severity and location of symptoms can vary depending on the specific form of the disease. More than 50 million adults have a doctor-diagnosed arthritis, which is 1 in 5 people over 18 years of age. Almost 300,000 babies and children have arthritis or a rheumatic condition affecting 1 in 250 children.

This has a huge impact on disability and cost, as reported by the CDC for states in Medica’s service area:

State  Adults with arthritis Adults limited by arthritis Total costs (in millions of dollars)
Minnesota 907,000 393,000 2,172
Wisconsin  1,104,000 479,000 2,445
Nebraska 334,000 137,000 757
Iowa 619,000 228,000 1,250
North Dakota 134,000 57,000 285
South Dakota 158,000 73,000 351
Kansas 536,000 228,000 1,106

The cost of arthritis and related conditions is significant: According to the Arthritis Foundation, lost wages and medical expenses total more than $156 billion annually, from more than 100 million outpatient visits and an estimated 6.7 million hospitalizations.

Helping patients, reducing costs
There is no sure way to prevent arthritis, but patients can reduce risk and manage symptoms. Here are some suggestions for patients to manage or delay the onset of certain types of arthritis:

  • Get regular exercise
  • Maintain a healthy weight
  • Do not smoke, or stop smoking
  • Eat healthy diets low in sugar
  • Moderate alcohol consumption
  • Avoid sports injuries, by using the proper equipment and adequately training

For patients with arthritis, there are possible treatments to manage the pain and discomfort associated with arthritis. Treatment may include:

  • Medications, including prescription drugs and over-the-counter pain relievers
  • Physical therapy with muscle strengthening exercises
  • Supportive devices such as crutches or canes
  • Surgery, if other treatment options have not been effective

Helping patients cope with the condition by keeping them active will help their well-being, will help slow the progression of arthritis, and, ultimately, may help reduce costs to the health care system.


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

Medica requires its Minnesota-based network providers to submit third-quarter 2017 quality-of-care complaint reports to Medica by October 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

Effective January 1, 2018:
Commercial cost-sharing to change for specialty drug discounts

Medica commercial group plan members who use a savings card for the purchase of their specialty drugs will see a change in the way drug manufacturer discounts get applied to member plans. Starting January 1, 2018, only the amount that members actually pay for their specialty drug, not the total cost of the drug, will apply to their plan's deductible and/or out-of-pocket maximum. The remaining amount paid through the savings card will not be applied to the deductible and/or out-of-pocket maximum. The drug discounts themselves will continue unchanged.

Medica is notifying members who have recently used a savings card to let them know that a change will begin on January 1. No retroactive out-of-pocket changes or adjustments will be made.

See more about this change. Details will also be available to members at This change was also implemented for Medica individual and family business (IFB) members as of July 1, 2017.

(Update to "Cost-sharing process to change for specialty drug savings cards" article in the July 2017 edition of Medica Connections.)

Effective October 13, 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, effective with October 13, 2017, dates of service. Prior authorization will be required for the corresponding medical pharmacy drugs.

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

Drug code Drug brand name Drug generic name
J9999 Aliqopa copanlisib
J9999 Besponsa inotuzumab ozogamicin
J9999 Kymriah  tisagenlecleucel 
J9999  Mylotarg  gemtuzumab ozogamicin 
J9999 Vyxeos cytarabine/daunorubicin

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. The policies will be subject to pre-payment claims edits as well.

These new medical pharmacy drug UM policies will be available online or on hard copy:

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Administrative News

Provider College administrative training topic for October

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 Notes
LC-WO Life of a Claim Oct. 17 10-11:30 am Class code with "WO" means offered via webinar in October

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 September 1, 2017:
Medica revises reimbursement policies

Medica has recently updated the reimbursement policies indicated below, effective on or after September 1, 2017, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.

Reimbursement policies - Revised

These versions replaced all previous versions.

Self-Administered Drugs (updated code list)
Supply (updated code lists)

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

The revised policies are available online or on hard copy:

Note: At the same time, Medica updated related code lists in the following reference guides:

  • Modifier Reference Guide
  • Place of Service (POS) Code Reference Guide


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.

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SelectCare/LaborCare News

Latest UHC provider bulletin available online

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

  • Prior authorization no longer required for Truvada
  • New prior authorization requirement for certain office-based procedures performed in other sites of service __ scheduled for October 2017
  • New prior authorization requirement for colony-stimulating factors administered to patients with a cancer diagnosis in the outpatient setting __ scheduled for October 2017
  • Multiple procedure payment reduction for diagnostic cardiovascular and ophthalmology procedures  __ delayed until November 2017
  • New clinical guideline on neonatal hyperbilirubinemia __ scheduled for November 2017
  • New reimbursement policy on acupuncture __ scheduled for December 2017

View the September 2017 UHC provider bulletin.

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Posted: September 27, 2017

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