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Provider Medica Connections

January 2018

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

General News

Medica Foundation publishes annual report on giving

The Medica Foundation recently released its most recent annual community report detailing grant investments and featuring the outstanding work of organizations that were funded. The Foundation distributed more than $1.2 million to the community through nearly 100 grants, which were awarded to providers and other nonprofit organizations working to improve health. These programs:

  • Responded to the opioid crisis by supporting a new treatment facility in Duluth, Minn., focused on people with high risks, including pregnant women and injecting-drug users
  • Addressed the trauma of Karen refugees through the nation’s first culturally specific chemical-dependency-intervention program started in St. Paul
  • Helped families throughout Minnesota prevent and reduce the effects of childhood adversity such as poverty and homelessness

As these efforts and many others illustrate, the Foundation’s assistance to improve the health of those in need across different cultures and life experiences continues. The Foundation funds community-based initiatives and programs that support community needs by improving health and removing barriers to health care services. As the charitable giving arm of Medica, the nonprofit Foundation distributes grants each year based on health-related criteria. 2018 funding opportunities will be announced in February. Learn more and see the annual report.


Due by December 30, 2017:
Compliance, FWA trainings due 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 each year. 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.

According to federal regulations, providers must use the general compliance and FWA training materials created by CMS. The form confirming this training has been completed is due back to Medica by December 30, 2017. Learn more and take the trainings (under “Provider Training”).

Medica would like to thank all providers who have already returned their form in a timely manner.

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Clinical News

Medical policies and clinical guidelines updated regularly

Medica regularly updates utilization management (UM) policies, coverage policies and clinical guidelines. However, there will be no policy changes effective February 19, 2018, as previously published. 

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 policies themselves are then available online or on hard copy:

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


Survey coming in January 2018!
Requesting providers' input on patient access to care

Soon, Medica will be asking for provider feedback on patient access to care, including activities like care coordination, referrals to specialists and availability of clinic appointments. This survey will be intended for primary care, specialty care and behavioral health provider offices. Those who are signed up to receive Medica Connections can look for the survey coming electronically by mid-January 2018. Survey responses will be confidential and grouped with other results.

Provider surveys like this allow Medica to improve service to providers and members. For instance, Medica asked network providers in September 2017 about satisfaction with its utilization management (UM) services, such as prior authorization. As a result, starting January 1, 2018, Medica will begin adding billing codes to its Prior Authorization List that may be included in the prior authorization requirement for each procedure or service. After past surveys, Medica has updated its UM processes, such as refining prior authorization request forms and UM policies and making them easily accessible at

Medica would like to thank providers for giving their valuable feedback!


Coming in February - May 2018:
Upcoming chart reviews needed for HEDIS quality reporting

Providers are encouraged to advise their staff of an upcoming period for clinic chart reviews, which will be ongoing from February until May 2018. Medica quality reviewers (nurses) will contact clinics to set up a site visit or determine another authorized method to collect the requested information.

This upcoming effort is due to annual reporting requirements for the Healthcare Effectiveness Data and Information Set (HEDIS®), a set of standardized quality-performance measures developed by the National Committee for Quality Assurance (NCQA) allowing for comparison across health plans. Through this program, NCQA holds Medica accountable for the timeliness and quality of its health care services. As both state and federal governments move toward a health care industry that is driven by quality, HEDIS rates are becoming more important not only to the health plan but to individual providers as well.

As an example, state purchasers of health care use aggregated HEDIS rates to evaluate the effectiveness of Medica’s preventive outreach efforts. Physician-specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician profiling and incentive programs. See more about HEDIS.

As a reminder, protected health information (PHI) that is disclosed for purposes of treatment, payment or healthcare operations is permitted by privacy rules according to the Health Insurance Portability and Accountability Act (HIPAA) and does not require consent or authorization from the member or patient. The provider responsibilities regarding medical records requests are explained in the Medica provider administrative manual, which is considered part of the provider contract with Medica.

Due by January 15, 2018:
Quality complaint reports required by State of Minnesota

Medica requires its Minnesota-based network providers to submit fourth-quarter 2017 quality-of-care complaint reports to Medica by January 15, 2018.

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

Hemophilia case review, prior authorization forms now online

As previously published, Medica will begin requiring prior authorization for hemophilia factor products beginning with January 1, 2018, dates of service. Practitioner offices need to request prior authorization and dispensing pharmacies need to complete a hemophilia case review form prior to dispensing these products. Medica is also implementing new medical pharmacy drug utilization management (UM) policies listing these affected hemophilia drugs as well as requirements for them.

The new hemophilia forms and policies are now 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 a 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.

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Administrative News

Provider College administrative training topic for January

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
"Medica Medicare Products" (class code: MM)
This course will review information to assist providers to better understand the different Medicare plans Medica has available. Topics include: the difference between Medicare Advantage and Cost plans; when Medica follows Centers for Medicare and Medicaid Services (CMS) guidelines; when to bill Medica vs. Medicare as primary payer; upgraded services offered by plans; billing requirements; and reimbursement. Time will also be provided for questions and answers as part of this discussion.

Class schedule

Class code Topic Date Time Notes
MM-WJ Medica Medicare Products Jan. 30 10-11 am Class code with "WJ" means offered via webinar in January

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 February 1, 2018:
New policy on inpatient hospital readmissions delayed

Medica previously announced a new policy to address reimbursement of same-day readmissions to the same hospital under the same provider number, as billed on a facility claim form. Due to unforeseen circumstances, the implementation of this Inpatient Hospital Readmissions policy was delayed and it will instead become effective with February 1, 2018, dates of service.

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

This new policy will be available online or on hard copy:

(Update to "Medica to implement new reimbursement policy" article in the July 2017 edition of Medica Connections.)


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 (December 2017). Highlights that may be of interest to LaborCare® network providers include:

  • Prior authorization no longer required for CPAP
  • Refresher on submitting referrals vs. notification vs. prior authorization
  • Reminder: New list, policy address new-to-market drugs __ scheduled for January 2018     
  • New, revised emergency department (ED) facility E/M coding policies  __ scheduled for March 2018     

View the December 2017 UHC provider bulletin.

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Posted: December 21, 2017

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