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Provider Medica Connections

December 2017

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

General News

Dr. John Mach joins Medica as new chief medical officer

dr mach

John R. Mach, Jr., MD, recently joined Medica as chief medical officer (CMO), overseeing all Medica medical directors. Dr. Mach will work closely with the provider community and other stakeholder groups, providing overall clinical leadership in support of Medica’s quality management, clinical review and quality-of-care initiatives. He reports to Medica president and chief executive officer (CEO) John Naylor.

Dr. Mach has more than 31 years of medical experience across a broad range of roles. Most recently, he served as CMO for Evolent Health, where he provided leadership and strategic direction to more than 30 provider groups across the country. Prior to that, he served as president of complex care management at Univita Health, a national leader in home health care support programs. He also previously served as CEO of Evercare and CMO of Ovations, both part of UnitedHealth Group. Dr. Mach is a graduate of the University of Minnesota Medical School, where he completed his residency in internal medicine.



Verifying eligibility, benefits for patients new to Medica

Several large employer groups will newly enroll with Medica as of January 1, 2018, including the City of St. Paul and Starkey Hearing Technologies (in Eden Prairie, Minn.). The start of each year is a busy time as many patients switch health plans. Some employer groups customize their health plan to include unique benefit sets. It is therefore important that providers ask for a current member ID card and verify member eligibility and benefits to ensure the correct copayment is collected, when needed, at each visit. Having up-to-date member information also helps to ensure accurate and timely claims processing.


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Clinical News

Effective January 15, 2018:
Medical policies and clinical guidelines to be updated

Medica will soon update one or more utilization management (UM) policies, coverage policies and clinical guidelines. These upcoming policy changes will be effective January 15, 2018, unless otherwise noted.

These policies apply to all Medica properties 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 update notification for changes effective January 15, 2018, is already posted. Changes to policies are effective as of that date unless otherwise noted. 

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

Note: The next policy update notification will be posted in December 2017 for policies that will be changing effective February 19, 2018. These upcoming policy changes will be effective as of that February date unless otherwise noted.


Appropriate turnaround times for prior authorization requests

As a reminder regarding appropriate turnaround times for prior authorization requests, standard case reviews can take up to 2 weeks for a response from the Medica utilization management (UM) team. This standard timeline is compliance-driven and varies from state to state. It’s important for providers to understand and respect this guideline as it allows for prioritizing cases that need medical attention more urgently. It also protects a fair and equitable approach by Medica for all patients who are Medica members.

In urgent or emergency situations, providers are able to request an expedited prior authorization review. Generally, providers should anticipate up to 72 hours for expedited prior authorization reviews for all members in all health plans (other than in South Dakota). Medica undertakes an accelerated pre-service or concurrent review when any of the following circumstances apply:

  • The standard review timeframe could seriously jeopardize the member’s life, health or ability to regain maximum function, based on a prudent layperson’s judgment.
  • The standard review timeframe could, in the opinion of a practitioner with knowledge of the member’s medical condition, subject the member to severe pain that cannot be managed without the care or treatment being requested.
  • The attending health care professional requests an expedited review or believes that an expedited determination is warranted.

Note: Medica reserves the right to process a member’s request for expedited review in the standard timeframe when the above criteria are not met. A provider should apply these criteria before making requests for review. (Also, retrospective reviews, by definition, are not eligible for expedited review.)

The following table outlines pre-service standard and expedited review times for prior authorization requests, as well as turnaround times for concurrent reviews.

State Standard Pre-service
Expedited Pre-Service Reviews Concurrent Reviews
Minnesota 10 business days  72 hours 24 hours
North Dakota 14 calendar days  72 hours 24 hours
South Dakota 14 calendar days  24 hours 24 hours
Wisconsin 14 calendar days  72 hours 24 hours
Iowa 14 calendar days   72 hours 24 hours
Nebraska 10 business days  72 hours 24 hours
Kansas 15 calendar days   72 hours 24 hours

Medica’s UM team makes medical necessity determinations as expeditiously as the member’s health condition requires, but no later than the regulatory timeframes listed, and based upon the member’s plan document.

Also as a reminder: Medica network providers need to request prior authorization for services on the current Prior Authorization List. Medica will deny claims as provider liability for lack of prior authorization. Providers have 60 days to file an appeal after a denial. Only services on the Prior Authorization List require prior authorization. Providers should not request prior authorization for services not on this list.


Effective January 1, 2018:
Change to inpatient concurrent review for certain members
UnitedHealthcare to administer for some Passport members

Starting January 1, 2018, UnitedHealthcare will administer inpatient concurrent review on behalf of Medica for certain Medica Choice® Passport members (those in plans with six-digit group numbers). Concurrent review services are currently managed by Medica. Although UnitedHealthcare will assume responsibility for managing inpatient concurrent review for these members, cases that involve a potential denial of service will be forwarded to Medica. Medica will also continue to handle inpatient concurrent review for all other Medica members who are eligible.

Concurrent review includes evaluation of inpatient stays ("LOS" or “bed days”). Through this program, utilization nurses monitor appropriateness and level of care, the setting, and the progress of discharge plans for Medica members who are inpatient.

Notification of inpatient admission and prior authorization are required for all Medica members and should continue to be submitted to Medica. UnitedHealthcare may request clinical records on behalf of Medica for Medica Choice Passport members. Upon request, facilities are required to submit inpatient clinical records within one business day. Notification of admissions and timely responses to requests for medical records help ensure a timely review and communication of determinations.

UnitedHealthcare, on behalf of Medica, may review health services concurrently or retrospectively to determine if clinical documentation meets medical necessity criteria for these members. In either case, if inpatient medical necessity criteria are not met, claims may be denied as provider liability.

Identifying and treating patients with depression

Depression is more than just being sad or going through rough times. It’s a serious mental health condition that requires understanding and medical care. Although depression can be a devastating illness for patients, the condition can be treated effectively.

Screening, diagnosis
Simple screening questions may be an effective alternative to other complex instruments. One abbreviated tool used to assess and monitor depression severity is the Patient Health Questionnaire-9 (PHQ-9). This 9-question self-administered tool is quick and user-friendly, improves the recognition rate of depression, and facilitates diagnosis and treatment.

The best practice for the treatment of depression includes a treatment plan involving therapy, medication and self-empowerment or recovery tools.

According to the American Psychological Association (APA), psychotherapy may be considered as monotherapy for patients with mild to moderate major depressive disorder. Combining depression-focused psychotherapy and pharmacotherapy may be a useful initial treatment choice for patients with moderate to severe major depressive disorder. When pharmacotherapy is utilized, medication adherence is indicated for at least six months in order to prevent relapse.

Specialty care, other resources
Medica Behavioral Health is able to assist in finding network behavioral health practitioners for Medica patients, by referring to the MH/SA number on the back of the Medica member’s ID card for assistance.

Other resources to consider:

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Pharmacy News

Effective January 1, 2018:
Medica outlines upcoming changes to member formularies

As noted last month, Medica will be making changes in coverage status to member drug formularies (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. The changes to these formularies are now posted online.

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

New prescriptions help transition of specialty, mail order drugs

Medica published last month that it will soon transition to a new specialty drug vendor, Accredo Specialty Pharmacy, and new mail order vendor, CVS Caremark. These transitions will be effective with January 1, 2018, dates of service. Medica is working with Accredo and CVS to ensure that members continue to have access to their medications. These vendors may require a new prescription for some patients. Medica is notifying affected Medica members in late November about this, so provider offices may soon get requests for assistance with submitting prescriptions for specialty medications to Accredo or mail order medications to CVS Caremark. Providers can initiate these requests on behalf of patients beginning in December 2017 for dates of service beginning January 1, 2018. Medica appreciates prescribers’ patience during this transition period to ensure that all members are able to receive their medications when they need them. See more on drug mail orders at

New pharmacy program for hemophilia: 2 forms required

As indicated last month, Medica will begin requiring prior authorization for hemophilia factor products as of January 1, 2018, dates of service. In addition to practitioner offices requesting prior authorization, dispensing pharmacies will need to complete a hemophilia case review form prior to dispensing these products to ensure appropriate assay management, inventory management and patient engagement. Medica will also implement new medical pharmacy drug utilization management (UM) policies that will list affected hemophilia drugs as well as requirements for them. The new hemophilia policies and related request forms will soon be available at (under "Medical Benefit Applies"). Providers can start requesting prior authorization as of December 26, 2017, for dates of service beginning January 1, 2018.

If prior authorization is required for a medication included in the new hemophilia policy 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.

Note: Prior authorization and case review for hemophilia factor products will not be required for emergency or inpatient situations. This requirement also will not apply for Medica's Medicare members.


Effective February 1, 2018:
Medica to add new medical pharmacy claims-edit drug policy

Medica will soon implement the following new claims-edit policy for medical pharmacy drugs, effective with February 1, 2018, dates of service.

Medica pharmacy claims-edit policies — New

Drug code Drug brand name
Drug generic name
J0256, J0257 Aralast NP, Glassia, Prolastin-C, Zemaira alpha-1-proteinase inhibitors

This policy will apply to Medica commercial members, Minnesota Health Care Programs (MHCP) members and Medica Medicare members in Medica DUAL Solution® (Minnesota Senior Health Options, or MSHO) and Medica Advantage Solution® (Medicare Advantage). It will not apply to individual and family business (IFB) members or Medica Prime Solution® (Medicare Cost) members.

This new medical pharmacy claims-edit drug policy will be available online or on hard copy:

Combatting fraud related to boilerplate faxed prescriptions

Prevention is always the first step in defense against fraud, waste and abuse. Recently, Medica has experienced an increase in high-cost prescription drug claims originating from pharmacies, often located outside of Medica’s Upper Midwest service area.

At the direction of a prescriber, these pharmacies often mix various ingredients together to produce a non-commercially available product. Popular compounded products include pain creams and ointments that may contain a multitude of various potent medications. Many include drugs that could cause central nervous system depression or cardiac effects that result in slow breathing, a low or irregular heartbeat, drowsiness or a loss of consciousness. Often, there is little to no clinical evidence supporting the use of these potentially dangerous pharmaceutical products.

These pharmacies frequently engage marketers to make cold calls to members in order to obtain their Medicare or insurance ID numbers as well as to solicit compounded creams or pills. The pharmacies then submit a boilerplate form (like the example below) by fax to the member’s clinic and ask the member’s doctor to sign an order or prescription for the product, which the prescriber may misinterpret as a patient-requested product or a refill of a medication originally ordered by another prescriber. Often these compounded products result in claims worth thousands of dollars, an unnecessary and potentially fraudulent waste of health care dollars.


pharmacy fax example


What can prescribers do to prevent this potential fraud?

  • Verify that the medication requested is clinically appropriate and medically necessary for the member’s condition and is compatible with other medications the member may be taking.
  • Check directly with the member that he or she requested the medication and, if appropriate, discuss other lower-cost, in-network and more-appropriate options with the patient.
  • Notify Medica’s Special Investigation Unit of any suspicious prescription-authorization requests, particularly involving compounded medications or boilerplate prescription forms, by calling Medica’s fraud hotline at 952-992-2237 or 1-866-821-1331 or using Medica’s online fraud referral form.

As a reminder, the prevention of fraud and abuse is in everyone’s best interest!

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Administrative News

Effective March 1, 2018:
Credentialing to add new provider specialty designation

Effective March 1, 2018, Medica will add a new practitioner specialty to identify practitioners as part of their provider demographics (for instance, available in provider directories for Medica members to use). The new specialty is Pain Management. Practitioners with the appropriate training or education who would like to request Pain Management as their specialty can submit a Minnesota Uniform Practitioner Change Form, if already credentialed with Medica. Send the form or inquiries to For practitioners who are new or active but not yet credentialed with Medica (such as some anesthesia providers), learn more at about submitting initial credentialing applications to Medica.


Coming by January 1, 2018:
New electronic submission of documents for IFB claim appeals

Medica will soon add a new electronic capability online so providers can submit supplemental documentation related to certain claim adjustments or appeals. This process improvement is a secure submission step for Medica individual and family business (IFB) claims that have been denied. Initially, this electronic submission option will only be available for documentation supporting claims with group or policy number “IFB.”

Documentation typically submitted for appeals includes medical records, provider remittance advices (PRAs) and practice management notes. For IFB appeals, providers will be able to scan these documents, save the files to a desktop or hard drive, and then attach them to a new secure electronic form, which will be available by selecting the “group/policy #IFB” option on Medica’s Claim Adjustment or Appeal Request Form.

The secure electronic submission of documentation for IFB claim appeals will allow providers to support an appeal request more expeditiously, likely resolving such payment issues quicker. Claim adjustments or appeals often are submitted after claim denials due to potentially incorrect determinations of member eligibility or benefits, a lack of prior authorization, or other reasons.

Note: Providers will be able to continue to use traditional appeal avenues for Medica IFB claim denials, by mail or fax, as needed. And providers need to continue using mail or fax to submit documentation related to claim appeals for all other Medica claims (other than IFB).


Effective January 1, 2018:
Annual reimbursement policy code-list updates scheduled

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

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

Add-On Code (updated code list)
Anesthesia (updated code list)
Assistant Surgeon (updated code list)
Bilateral Procedures (updated code list)
Bundled Services (updated code list)
Care Plan Oversight (updated code list)
Contrast and Radiopharmaceutical Materials (updated code list)
Co-Surgeon/Team Surgeon (updated code list)
Global Days (updated code list)
Injection and Infusion Services (updated code list)
Laboratory Services (updated code list)
Multiple Procedure Payment Reduction for Diagnostic Imaging (updated code list)
Multiple Procedure Reduction (updated code list)
Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction (updated code list)
Physical Medicine & Rehabilitation: PT, OT and Evaluation & Management (updated code list)
Preventive Medicine and Screening (updated code list)
Professional and Technical Components (updated code list)
Prolonged Services (updated code list)
Same Day Same Service (updated code list)
Self-Administered Drugs (updated code list)
Services and Modifiers Not Reimbursable to Health Care Professionals (updated code list)
Telemedicine (updated code list

These changes 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:

How to bill for community EMT services for MHCP members

As a reminder, Medica covers community emergency medical technician (CEMT) services provided to Minnesota Health Care Programs (MHCP) members, effective as of January 1, 2017. Based on guidelines outlined by the Minnesota Department of Human Services (DHS), MHCP members are eligible for CEMT services if they have recently been discharged from an inpatient stay in a hospital, recently been discharged from a nursing home, or made repeated calls for assistance at their homes.

Under the CEMT benefit, certified CEMTs need to bill under the national provider identifier (NPI) number of their provider group's medical director employing CEMTs, using a CMS-1500 paper claim form or the professional (837P) electronic claim format. The following billing specifications apply:

  • Indicate place-of-service code 12 (home).
  • Code T1016 with modifier U4 for a post-discharge visit (maximum of 4 units).
  • Code T1016 with modifier U5 for a safe home visit (maximum of 4 units).
  • Bill in 15-minutes increments, where 1 unit = 15 minutes.
  • Do not bill for travel time, mileage, or services related to hospital-acquired conditions or treatments.

CEMT services must be part of a care plan ordered by a primary care provider. For more details, refer to the DHS website.


Billing best practices: Coding specificity, documentation 

October 1, 2017, marked the second anniversary of the implementation of ICD-10 diagnosis codes (International Classification of Diseases, Tenth Revision). Health care providers use this system to classify and code all diagnoses, symptoms and procedures recorded for care in the United States.

Each October, there are new guidelines and code changes, additions and deletions. The one thing that remains constant is a focus on specificity. The goal is to capture the most specific diagnosis for which the patient is being seen and treated at the time of a visit. Some tips to remember when documenting a visit are:

  • Document all conditions that have an impact on patient care.
  • Document conditions that coexist at the time of the visit and require treatment.
  • Distinguish between acute and chronic.
  • Identify disease manifestations by including a linking statement (e.g., neuropathy due to Type II diabetes).
  • If a condition is still active and being treated, do not indicate “history of.”
  • If a condition has been resolved, don’t document as “active.”
  • Distinguish and identify as applicable: left, right or bilateral.

With detailed documentation and appropriate ICD-10 coding, providers as well as payers can now ensure that specific details and pertinent information relevant to each patient encounter are captured.

More information is available from the Centers for Disease Control and Prevention (CDC) or the professional coding association AAPC.

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SelectCare/LaborCare News

Latest UHC provider bulletin available online

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

  • Tips on inquiry, response for member eligibility and benefits (EDI transactions 270/271)
  • Some genetic and molecular outpatient lab tests now require prior authorization
  • Medical record reviews for 2017 dates of service — scheduled for December through March
  • New list, policy address new-to-market drugs — scheduled for January 2018

View the November 2017 UHC provider bulletin.

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Posted: November 22, 2017

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