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Provider Medica Connections

November 2017

General News | Clinical News | Pharmacy News | Network NewsAdministrative News | SelectCare/LaborCare News

General News

Effective January 1, 2018:
Medica to launch new Medicare Advantage product

Effective January 1, 2018, Medica is introducing Medica Advantage Solution® (HMO-POS), a new Medicare Advantage product in the Twin Cities metro area. It will offer a broad provider network that includes major health care systems such as:

  • Allina Health
  • Fairview Health Services/HealthEast Care System
  • Hennepin County Medical Center (HCMC)
  • Ridgeview Medical Center & Clinics
  • North Memorial Health
  • CentraCare Health

Medica Advantage Solution will include both medical and Part D drug coverage and provide protection from unlimited out-of-pocket costs. The first plan option, Medica Advantage Solution, will include these benefits and features on January 1:

  • $0 deductible for in-network medical benefits
  • $5,900 annual out-of-pocket maximum
  • $25 copay for primary care office visits
  • $50 copay for specialist office visits
  • $0 copay for Medicare-covered preventive services
  • $80 copay for emergency care in the U.S.
  • 20% coinsurance for worldwide emergency coverage
  • Free fitness center membership through SilverSneakers®
  • $0 copay for e-visits through virtuwell®
  • $25 copay for routine vision and hearing exams
  • A point-of-service (POS) benefit that provides out-of-network coverage for most services when you travel throughout the U.S. at any provider that accepts Medicare (after a $250 POS deductible) 
  • Part D drugs with $0 copay for tier 1, $4 copay for tier 2, $40 copay for tier 3, 50% coinsurance for tier 4 and 28% for tier 5 drugs (after a $250 Part D deductible). For tiers 1-3, a mail order option provides a three-month supply for only two copays.

A fact sheet for this new Medicare product is available at (under Medicare Products).


Effective January 1, 2018:
Medica makes benefit changes to Medicare Cost, MSHO plans

Effective January 1, 2018, Medica is making several benefit changes to its Medica Prime Solution® product (for Medicare Cost plan members) and Medica DUAL Solution® product (for Minnesota Senior Health Options, or MSHO, members).

Cost plans
Medica will consolidate plan designs and add new plans for its Medica Prime Solution product. A notable change will be for Part B drugs, which will become member liability. It is important that members are aware of upcoming changes and review all plan options available to them during the annual enrollment period that runs from October 15 to December 7, 2017. Highlights of plan changes:

  • North Dakota, South Dakota and Wisconsin have new plan names and benefit designs.
  • Members can enroll in medical-only plans (with no Part D) via
  • Part B drug cost-sharing will apply in addition to primary/specialist office visit copays. Members affected by this change will receive a follow-up letter in addition to their Annual Notice of Change mailing.
  • Most plans include higher cost-sharing for advanced imaging services.
  • Most premiums are only 4-6% higher next year, some due to richer benefit designs.
  • Medica’s Part D options have low cost-sharing for tiers 1 and 2 without requiring preferred pharmacies.

Medica’s Part D formulary will change as of January 1, 2018. Medica Prime Solution members with Part D coverage received a copy of the new formulary in their Annual Notice of Change mailing this fall. All Medica Part D plans will use the same broad 5-tier formulary that covers more than 3,400 prescription drugs. Tiers were determined by the cost of the drug. Generic and brand-name drugs can be found across various tiers.

All Medicare members will receive a new ID card in December 2017. Medica anticipates higher-than-average plan switching during the annual enrollment period, so providers are encouraged to ask to see new patient ID cards after January 1, 2018, to be sure to have current plan information.

MSHO plan
Medica will add two mandatory supplemental benefits to its Medica DUAL Solution plan, and these changes will have an impact on network providers. The first new benefit is an upgrade to the existing eyewear benefit that allows a member to receive an anti-reflective glare premium coating on up to one pair of their eyeglasses. For this new benefit:

  • Eligibility applies only to Medica members with group 07XXX.
  • CPT code is V2750 and applies per lens; a full lens job, for 2 lenses = 2V2750.
  • Eligibility is limited to once every 24 months.
  • Providers continue to bill as they do now for the eyewear benefit.

The second benefit is individual nutritional counseling sessions that waive the requirement for medical necessity. Medica’s intent is to encourage members to take a more proactive role in healthy nutrition. For this new benefit:

  • Eligibility applies only to Medica members with group 07XXX.
  • CPT codes are 97802 and 97803.
  • Eligibility is limited to 7 sessions within the contract year.
  • Providers continue to bill as they do now for the professional services.

Updated fact sheets for these Medicare products will be available at (under Medicare Products) later this year.


Effective January 1, 2018: 
Medica makes IFB product changes for North Dakota and Iowa

As previously published, Medica is making several changes to its individual and family business (IFB) product offering effective January 1, 2018. In addition to the IFB updates for Minnesota, Nebraska, Kansas and Wisconsin, there are several updates for North Dakota and Iowa recently approved and also planned for January 1:

  • Although Medica Applause® will continue to be available in Minnesota, it will be replaced by Medica Individual Choice℠ in North Dakota. These new IFB N.D. plans will only be available off the federal Marketplace exchange.
  • For certain counties in Iowa, Inspire by Medica℠ will be a new IFB care-system product featuring UnityPoint Health, as part of a network through Midlands Choice.
  • Medica with CHI Health℠ will be a new IFB care-system product for certain counties in Iowa, as well as for Nebraska, featuring CHI Health (i.e., Catholic Health Initiatives) as part of a network through Midlands Choice.
  • The Medica Insure℠ open-access IFB product will offer tiered networks in Iowa as well as in Nebraska. The tier 1 (preferred) network will include Avera Health and UnityPoint Health in Iowa. While the sales area footprint will continue to be statewide in Nebraska, it will shrink in Iowa.

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


Effective for 2018:
Medica continues to serve Medicare members in North Dakota

As a clarification to recent news coverage on Medica’s withdrawal from the individual market ( in North Dakota, Medica wants to reassure N.D. providers that Medica is not leaving the N.D. Medicare market, and will continue to serve N.D. Medicare members with Medica Prime Solution® plans (Medicare Cost plans) next year. “Medica is committed to serving North Dakota seniors and will continue to provide Medicare options in 2018 and beyond,” said Tom Lindquist, senior vice president for government programs at Medica.

Annual notice:
Compliance, FWA trainings required for Medicare providers

The Centers for Medicare and Medicaid Services (CMS) requires that Medicare providers complete general compliance training and fraud, waste, and abuse (FWA) training. The training requirement applies to all organizations that provide health care services or administrative services for Medicare beneficiaries, and also applies to the organizations' downstream and related entities. Although Medicare-certified (or deemed) providers are exempt from the FWA portion of the training, they are still required to complete general compliance training.

Medica makes the Medica Standards of Conduct, Compliance Reporting Policy, and links to the CMS general compliance training and FWA training available on Medica also requires that a compliance officer or equivalent person for a provider group complete and sign a Compliance Program Attestation and return it to Medica. This is due by November 30, 2017.

According to federal regulations, providers must use the general compliance and FWA training materials created by CMS. Learn more and take the trainings (click on “Provider Training”).

As a reminder, training is required at the time of a Medicare provider's initial contract and then annually thereafter. Providers should maintain records of all training for 10 years. Records should include dates and methods of training, materials used for training, and training logs identifying employees who received training. Medica, CMS, or agents of CMS may request such records to verify that training occurred.

Effective January 1, 2018:
New MHCP demographic requirement for provider directories

Effective January 1, 2018, the Centers for Medicare and Medicaid Services (CMS) has new information requirements that pertain to provider directories for all Minnesota Health Care Programs (MHCP) products. Medica MHCP products affected are:

  • Medica AccessAbility Solution® (for Special Needs Basic Care, or SNBC)
  • Medica DUAL Solution® (for Minnesota Senior Health Options, or MSHO)
  • Medica Choice Care℠ MSC+ (for Minnesota Senior Care Plus)

The new provider directory information requirements, which providers must furnish to health plans, include:

  • The provider’s website URL, if available
  • The provider’s cultural competency, demonstrated by completion of specific training (such as this CMS training)
  • The provider’s office accessibility to patients with physical disabilities, demonstrated by compliance with Americans with Disabilities Act (ADA) standards

These new information requirements pertain to both print and online provider directories. Later this year, providers can conveniently provide this information by visiting the Providers home page on, logging in to the secure Electronic Transactions provider portal on, and using the Provider Demographic-Update Online Tool (PDOT), under “Update: Regulatory Requirements.”

After January 1, 2018, providers can continue to use PDOT as the primary way to update this information, similar to all other demographic data, within 30 calendar days of a change.

Effective January 1, 2018:
Diabetic supplies only covered when purchased at pharmacies

Medica is making a benefit change for commercial plan members and individual and family business (IFB) members in 2018. These members will need to purchase certain diabetic supplies at Medica network pharmacies, rather than through durable medical equipment (DME) providers, for Medica to provide coverage for the expense. This will apply only to the following DME and disposable diabetic supplies: glucose meters, test strips, lancets, syringes/needles and alcohol swabs.

This change will be effective for IFB members as of January 1, 2018, and for commercial members as their employer group enrolls or renews with Medica on or after January 1, 2018.

This benefit change will not apply to insulin pumps and supplies for insulin pumps, which members can continue to purchase from DME vendors.

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Clinical News

Effective January 1, 2018:
Medica policies and clinical guidelines to be updated

Medica will soon update one or more utilization management (UM) policies, coverage policies and Medica clinical guidelines effective January 1, 2018, unless otherwise noted. These policies apply to all Medica products including commercial, government, and individual and family business (IFB) products unless other requirements apply due to state or federal mandated coverage, for example, or coverage criteria from the Centers for Medicare and Medicaid Services (CMS).

Monthly update notifications for Medica's policies are available on an ongoing basis. Update notifications are posted on prior to their effective date. The medical policy changes effective January 1, 2018, are already posted. Policy changes are effective as of that date unless otherwise noted.

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

Note: The next policy update notifications will be posted in November 2017 for policies that will be changing effective January 15, 2018. These upcoming policy changes will be effective as of that January date unless otherwise noted.

Also effective January 1, 2018, Medica will be making changes to clinical guidelines. Medica’s new clinical guidelines will align with national professional organizations and other health care specialty societies that develop clinical guidelines, such as the American Diabetes Association (ADA), American Heart Association and U.S. Preventive Services Task Force (USPSTF). Medica will continue to develop and maintain its own proprietary clinical guidelines as necessary, in addition to the external guidelines. The goal with the change in clinical guidelines is to promote nationwide best practices. Medica encourages providers to follow specialty guidelines wherever they serve Medica’s members. References to specialty society clinical guidelines will be available on


Effective January 1, 2018:
Medica to make changes to Prior Authorization List

The Medica Prior Authorization List is routinely updated to reflect any changes involving prior authorization requirements, typically indicated in utilization management (UM) policies. As of January 1, 2018, and going forward, this list will also be updated to include inpatient notification requirements, where needed, as well as billing codes that may be included in the prior authorization requirement for each procedure or service. Refer to the current Prior Authorization List.

As a reminder, Medica requires that providers obtain prior authorization before rendering services. If any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. See more about prior authorization.

By instituting prior authorization, Medica aims to support members and providers in making evidence-based decisions about appropriate, medically necessary care.

Assessing and treating patients who have diabetes

Together with providers, Medica is committed to ensuring optimal health for its members by providing unwavering, high-quality care. With this promise, a comprehensive focus on diabetes care is vital for many members to reach or maintain their optimal health and well-being.

Diabetes is a widespread disease that comes with very serious health consequences if not carefully managed. Regular testing and exams for diabetic patients is key for maintaining optimal health. These assessments and treatments include regular hemoglobin A1c testing, annual renal function screening, and retinal eye and neuropathy exams.

Over the past few years, there have been steady improvements in patients achieving recommended hemoglobin A1c levels. However, 33-49 percent of patients still do not meet recommended targets for glycemic control. The American Diabetes Association (ADA) recommends hemoglobin A1c measurement 3-4 times per year for type 1 and poorly controlled type 2 diabetic patients, and 2 times per year for well-controlled type 2 diabetic patients. This important test monitors glucose control over time, allowing providers to make adjustments to a patient’s diabetes treatment, if necessary, and reduce the risks of diabetes-related complications.

As a leading cause of end-stage renal disease (ESRD), diabetes requires careful glucose control and blood pressure reduction. Both are crucial to reducing onset and progression of nephropathy. To prevent progression of nephropathy and reduce the risk of cardiovascular disease, nephropathy screening and blood pressure control are important for patients with diabetes. The ADA recommends annual screening for microalbuminuria following an initial diabetes diagnosis and annually thereafter. This close screening allows for early identification of nephropathy and is necessary prior to starting interventions that help slow its progression.

Diabetic retinopathy is a leading cause of blindness in middle-aged adults. Maintaining optimal glycemic management and blood pressure control can reduce risk of retinopathy, or slow its progression. To identify diabetic patients at risk for vision loss, regular screening for retinopathy is essential. Dilated retinal exams should be done upon initial diagnosis of diabetes and annually thereafter when following the recommendations from the ADA.

Diabetic neuropathies are the most prevalent chronic complication of diabetes. Prevention is key as there are few treatments that target the underlying nerve damage. Screening for symptoms and signs of diabetic neuropathy is critical in clinical practice. All patients should be assessed for neuropathies starting at diagnosis of diabetes and annually thereafter.

Patient education and targeted approaches to support disease self-management should be focused on medication adherence and shared decision-making. Barriers to care adherence may include a complex medication schedule, cost, or negative side effects. A patient-centered conversation can help identify barriers to adherence and promote self-care. Within this discussion, providers should also emphasize healthy lifestyle choices such as healthy eating, physical activity, tobacco cessation, weight management, self-monitoring of glucose and blood pressure as key education points for optimal diabetes self-care. Ways to incorporate shared decision-making into clinical practice include promoting patient-selected self-goals within diabetes care plans.

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Pharmacy News

Effective January 1, 2018:
Medica plans to update member formularies 

Medica is reviewing several medications and will be making changes in coverage status to drug formularies (or drug lists) effective January 1, 2018. For certain Medica members, as noted below, these changes would be effective January 1, 2018, for new prescriptions, but not effective until February 1, 2018, for existing prescriptions.

These upcoming changes may apply to one or more of the following drug formularies:

  • 2018 Medica Commercial Large Group Drug List — effective 1/1 for new prescriptions, 2/1 for existing
  • 2018 Medica Commercial Small Group Drug List
  • 2018 Medica Preferred Drug Lists for individual and family business (IFB)
  • 2018 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP) — effective 1/1 for new prescriptions, 2/1 for existing

The Medica MHCP formulary applies to the following products: Medica Choice Care℠ (for Minnesota Senior Care Plus program, or MSC+), 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. More about upcoming changes that will apply to Medica Medicare Part D formularies is included below.

Medica will post changes to its drug formularies on 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

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.

Effective January 1, 2018:
Accredo selected as new vendor for specialty pharmacy services

Medica has selected Accredo® Specialty Pharmacy as its new preferred specialty pharmacy vendor as of January 1, 2018. Accredo will handle specialty medications for Medica’s commercial, individual and family business (IFB) and Minnesota Health Care Programs (MHCP) members. Medica's Medicare Part D plan members will also have access to Accredo as Medica's preferred specialty pharmacy vendor. Accredo provides the broadest access to exclusive and limited-distribution drugs in the industry.

For the upcoming transition, as of January 1, 2018, Accredo will coordinate open-refill transfer files to move members who have current specialty drug prescriptions. Accredo is able to offer additional member support during the transition and will provide specialty prescription refill assistance. If certain members need a more hands-on transition, Accredo offers manual pharmacist-to-pharmacist transfers as well as targeted outreach calls to obtain prescriptions. Medica will notify affected members in late October. For more on this transition of specialty medication services, refer to

Specialty prescription refills can continue to go to the current specialty pharmacy through the end of this year. Later refill requests will be forwarded to Accredo to fill after January 1, 2018.

Note: As of January 1, 2018, Medica is not planning to make significant changes to current specialty drug lists.

Effective January 1, 2018:
Medica selects CVS Caremark for mail order pharmacy services

Starting January 1, 2018, CVS Caremark® Mail Service Pharmacy will be Medica’s new prescription mail order vendor for Medica’s commercial and Medicare Part D plan members. At the same time, CVS Caremark will begin handling mail service for Medica’s individual and family business (IFB) members.

Current mail order prescription refills will transfer to CVS Caremark Mail Service Pharmacy as of January 1, 2018. In certain situations, Medica members will need to request a new 90-day prescription from CVS Caremark to continue receiving prescription mail order service. In late October, Medica is notifying its members who regularly use mail order services.

Members can continue to request mail order prescription refills through their current mail service pharmacy through December 30, 2017. Later refill requests will be forwarded to CVS Caremark Mail Service Pharmacy to fill after January 1, 2018. See more information about this upcoming change.

Effective January 1, 2018:
Medical pharmacy drug UM program expanding to include Medicare

Effective January 1, 2018, the current medical pharmacy drug utilization management (UM) program will expand to include certain Medica Medicare members. This expanded program, which will continue to be administered by Magellan Rx, will apply to Medica DUAL Solution® members (in Minnesota Senior Health Options, or MSHO) and Medica Advantage Solution® members (in Medicare Advantage). Learn more about medical benefit drugs and see related drug policies.

The list of drugs included for this program, as well as the prior authorization process itself for the affected medications, will remain the same for January 1, 2018.

Effective January 1, 2018:
New pharmacy program to focus on managing hemophilia

Beginning January 1, 2018, Medica will require prior authorization for hemophilia factor products. This new pharmacy program, which will be administered by Magellan Rx, is intended to improve transparency around clinical management. Dispensing pharmacies will be asked to complete a hemophilia case review form prior to dispensing these products to ensure appropriate assay management, inventory management and patient engagement.

Prior authorization for hemophilia drugs will be required for Medica commercial, individual and family business (IFB), and Minnesota Health Care Programs (MHCP) members. This requirement will not apply for Medica’s Medicare members. Prior authorization will be added for the following drugs effective January 1, 2018:

Drug name Generic name J-code
Advate Recombinant Factor VIII J7192
Adynovate Recombinant Factor VIII (pegylated) J7207
Afstyla Recombinant Factor VIII J7199, C9140
Alphanate Factor VIII/VWF Combination Complex J7186
Alphanine SD Human Plasma Derived Factor IX J7193
 Alprolix Recombinant Factor IX J7201
 Bebulin Factor IX Complex J7194
BeneFIX Recombiant Factor IX J7195
Coagadex Human Plasma Derived Factor X J7175
 Corifact Human Plasma Derived Factor XIII J7180
 Eloctate Recombinant Factor VIII J7205
 Feiba, Feiba NF Anti-Inhibitor Coagulant Complex J7198
 Helixate FS Recombinant Factor VIII J7192
Hemofil M Human Plasma Derived Factor VIII J7190
Humate-P Factor VIII/VWF Combination Complex J7187
Idelvion Recombinant Factor IX (albumin fusion protein) J7202
Ixinity Recombinant Factor IX J7195
Koate DVI Human Plasma Derived Factor VIII J7190
Kogenate FS Recombinant Factor VIII J7192
Kovaltry  Recombinant Factor VIII J7192
Monoclate-P Human Plasma Derived Factor VIII J7190
Mononine Human Plasma Derived Factor IX J7193
Novoeight Recombinant Factor VIII J7182
NovoSeven RT Recombinant Factor VIIa J7189
Nuwiq Recombinant Factor VIII J7209
Obizur Recombinant Factor VIII (porcine sequence/recombinant) J7188
Profilnine Factor IX Complex J7194
Rebinyn Recombinant Factor IX (GlycoPEGylated) J7195
Recombinate Recombinant Factor VIII J7192
Rixubis Recombinant Factor IX


Tretten  Recombinant Factor XIII A-subunit J7181
Vonvendi Recombinant Von Willebrand Factor (VWF)  J7179
Wilate Factor VIII/VWF Combination Complex J7183
Xyntha Recombinant Factor VIII J7185

Effective January 1, Medica will implement a new medical pharmacy drug utilization management (UM) policy titled “Hemophilia Products” that will list these affected hemophilia drugs as well as requirements for them. Providers can watch for more details about this new hemophilia drug program in the coming months, including the new drug UM policy and a new prior authorization form that providers will need to submit for services starting January 1, 2018. Providers will be able to find such related materials at (under "Medical Benefit Applies").

Note: If prior authorization is required for one of the above medications but providers have not obtained it effective with January 1, 2018, dates of service, related claims will be denied as provider liability. Providers will have 60 days from the date of denial to submit a claim appeal.

Effective January 1, 2018:
Medica to make annual update to Part D drug formularies

Medica has made annual decisions on drugs that will either be removed from the Medica Medicare Part D drug formularies or be subject to a change in preferred or tiered cost-sharing status effective January 1, 2018. The 2018 Part D formularies for Medica Prime Solution® members and Medica DUAL Solution® members are posted on Members are encouraged to review their formulary to see if any of their medications are changing.

Providers can also refer to a comprehensive list of all previous Medica Medicare Part D drug formulary changes. View Medicare Part D drug formulary changes on

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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Network News

Effective January 1, 2018:
Medica to update Medicare physician fee schedule

Beginning with January 1, 2018, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will coincide with the implementation from the Centers for Medicare and Medicaid Services (CMS).

This fee schedule change incorporates CMS relative value units (RVUs) and the conversion factor for year 2018 as well as various Medicare non-RVU fee maximums (such as labs, injections, immunizations, etc.). In addition, Medica will also update its Medicare fee schedule with rates for codes without a fee maximum established. Overall reimbursement for providers will depend on specialty and mix of services provided.

Details on Medicare changes to drug fees are available from CMS. Providers who have further questions may contact their Medica contract manager.

Second-quarter PCR checks to be mailed in October 2017

By the end of October 2017, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the second quarter of 2017. This represents a 100-percent return of the second-quarter 2017 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of April 1, 2017, through June 30, 2017, and dates paid of April 1, 2017, through September 30, 2017.

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Administrative News

Provider College offers new MSHO provider training

The Medica Provider College has posted a new “Model of Care” training regarding the Medica DUAL Solution® product, for enrollees in the Minnesota Senior Health Options (MSHO) program. Providers who see Medica DUAL Solution members are encouraged to take this self-guided training to learn about what Medica’s MSHO product offers and the importance of the provider’s role as part of each MSHO patient’s interdisciplinary care team. Learn more.

MSHO is a fully integrated program for Medicaid, Medicare, Part D and elderly waiver benefits, which for Medica DUAL Solution members are managed by Medica. The Centers for Medicare and Medicaid Services (CMS) requires that Special Needs Plans (SNP) like Medica DUAL Solution have a Model of Care, which is considered a vital quality improvement tool and an integral component for ensuring that unique needs of each beneficiary enrolled in a SNP are identified and addressed.


Provider College administrative training topic for November

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
"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
RH-WN Resources for Helping Yourself Nov. 14 10-11 am Class code with "WN" means offered via webinar in November

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, 2018:
Medicare therapy claims to require modifiers for payment

Effective January 1, 2018, claims for therapy services provided to Medicare members will need to include therapy modifiers GN, GO or GP in order to be paid. This change, based on a requirement from the Centers for Medicare and Medicaid Services (CMS), will apply to the following types of service provided in outpatient therapy settings and billed on either a professional or a facility claim: occupational therapy (OT), physical therapy (PT) and speech-language pathology services (SLP). Beginning with January 1, 2018, dates of service, claims that do not have the appropriate therapy modifiers listed will be denied as provider liability.

This change will apply for Medica’s Medicare members in the Medica Prime Solution®, Medica DUAL Solution® and Medica Advantage Solution® products.


Effective January 1, 2018:
Medica to revise reimbursement policy

Medica will soon update the reimbursement policy indicated below, effective beginning with January 1, 2018, dates of service. Such policies define when specific services are reimbursable based on the reported codes.

Split surgical package
A surgical package consists of the pre-operative management, surgical care and post-operative management services associated with a surgical procedure. Starting January 1, 2018, codes appended with modifiers 54, 55 and 56 will be reimbursed at the following percentages.

Modifier Description Reimbursement 
54 Surgical Care Only 80%
55 Post-operative Management Only 20%
56 Pre-operative Management Only 0%

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

The revised policy related to the above change will be available online or on hard copy:

Effective October 1, 2017:
Minnesota DHS rolls out new form for nursing facilities

The Minnesota Department of Human Resources (DHS) requires that nursing facilities use a new Nursing Facility Communication Form for Minnesota Health Care Programs (MHCP) products. This new form was effective October 1, 2017. The Medica MHCP products affected are Medica AccessAbility Solution® (for Special Needs Basic Care, or SNBC); Medica DUAL Solution® (for Minnesota Senior Health Options, or MSHO); and Medica Choice Care MSC+ (for Minnesota Senior Care Plus).

Nursing facility providers can find an example of a Medica-preferred completed form sample at the Claim Tools page on “Skilled Nursing Facility”). Best practices for filling out this form include:

  • Fill out this form electronically, save it, and then e-mail it to to ensure a timely response.
  • Always include the actual dollar amount in the Member Tracking Information section of the form (this information is vital to properly reimburse the provider).
  • Include this form with additional member documents for skilled benefit stays and fax all documents to 952-992-2299.
  • Direct any questions to the Medica Provider Service Center at 1-800-458-5512.

The new form is required from nursing facility providers whether the member has a skilled nursing facility benefit or custodial nursing facility admission, as well as when the member’s status changes (such as a discharge). Once a MHCP patient’s nursing facility benefit period with Medica ends, Medica will notify both DHS and the nursing facility using this new form.   

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
Adding general and payment protocols (from provider contracts), specific to multiple provider types New "Protocols" section November 2017

For the current version, providers may view the Medica Provider Administrative Manual 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 (October 2017). Highlights that may be of interest to LaborCare® network providers include: 

  • Delayed revision to consultation services reimbursement policy —  previously scheduled for October 2017
  • New genetic and molecular lab testing notification requirement — scheduled for November 2017
  • New prior authorization requirement for chimeric antigen receptor T-cell (CAR-T) therapy — scheduled for January 2018
  • Prior authorization change for specialty medications Ilaris and Ocrevus — scheduled for January 2018

View the October 2017 UHC provider bulletin.

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Posted: October 25, 2017

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