Skip to Main Content

Provider Medica Connections

March 2018

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

General News


Medica Foundation announces provider grant recipients
2017 early childhood health grants total $300,000

In 2017, the Medica Foundation awarded early childhood health program grants totaling $300,000 to 13 nonprofit organizations. This cycle of grant-making provided funds to support early intervention programs that focus on healthy families to foster the optimal growth and development of young children. Two grants were awarded to provider groups: A Chance To Grow and The Family Partnership.

A Chance To Grow, in Minneapolis, will partner with Head Start to provide more children and more centers with critical vision screening, eye exams and glasses. Vision plays a key role in a child’s ability to learn and succeed in school. The Family Partnership, also located in Minneapolis, will develop a parent-child intervention that influences parenting practices among parents with Adverse Childhood Experiences (ACEs) history, enhances how parents interact with their children, and prevents or reverses impaired executive function in children cared for by these parents. This two-generation approach has a major impact on a family’s ability to thrive.

“We are proud to support these organizations and the people they serve,” said JoAnn Birkholz, director of the Medica Foundation.

The Medica Foundation seeks to improve community health by funding initiatives that are innovative in how care is delivered and have a high likelihood of creating long-term change. Details about past grant recipients as well as 2018 funding opportunities, giving guidelines and application deadlines are available online at


Effective May 1, 2018:
Upcoming change in processing ER claims for MRRP members

Effective May 1, 2018, Medica will modify its criteria used to process claims for emergency room (ER) services to be more in line with those of the Minnesota Department of Human Services (DHS). This change will only apply to Minnesota Health Care Programs (MHCP) recipients enrolled in the Minnesota Restricted Recipient Program (MRRP), and only apply to claims for services received at a non-designated hospital.

As of May 1, MRRP ER claims will be evaluated based upon procedure codes. If MRRP claims are not submitted for emergency services, as determined by the reported procedure codes, they may be denied beginning with May 1, 2018, dates of service, and identified with denial code 0167 (“Restricted Recipient”). Currently, Medica uses diagnosis codes to determine if MRRP claims are a true emergency and eligible for payment.

Note: Emergency health care services may be provided to a MRRP recipient without the authorization or referral of the primary care physician. This aspect is not changing. “Emergency” means a condition including labor and delivery that, if not immediately diagnosed and treated, could cause a person serious physical or mental disability, continuation of severe pain, or death.

For more details about this program, refer to:

As a reminder, providers should always use MN-ITS, the DHS eligibility-verification system, to verify if an MHCP patient is enrolled in MRRP. Designated providers are listed there.


Re-credentialing helps to ensure timely payment of claims

Medica’s health care providers are re-credentialed on a three-year cycle, and are encouraged to reply to reminders from Medica’s Credentialing staff about doing so. Making sure that providers are re-credentialed in a timely manner helps eliminate gaps in provider status that could cause claims to be processed as out-of-network, or get denied altogether. Keeping credentialing current with Medica helps ensure that claims are paid promptly and properly. An inactive credentialing status means an administrative termination from Medica’s provider network.

See an upcoming training on this topic below.


[Return to top]

Clinical News


Effective April 23, 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 April 23, 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 update notification for changes effective April 23, 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 March 2018 for policies that will be changing effective May 21, 2018. These upcoming policy changes will be effective as of that May date unless otherwise noted.


Reviewing medical records for proper diagnosis codes
Annual outreach needed for risk-adjustment data validation

Each year, Medica undertakes a review of medical records to evaluate risk adjustment of patients based on data validation (“RADv”). The Centers for Medicare and Medicaid Services (CMS) requires that health plans validate the ICD-10 diagnosis codes that are submitted for payment, through claims, by conducting a medical record review for documentation that supports these codes.

This retrospective medical record review applies to claims for Medica’s Medicare, commercial, and individual and family business (IFB) members. It ensures that ICD-10 codes are reported accurately for payment integrity and accuracy. It also helps health plans like Medica avoid payment “take-backs” from CMS, as well as fines.

As a result of the CMS requirement, Medica reaches out to provider offices to request this review of medical records. Providers have the option to either send the records to Medica or schedule an on-site record review. As required by CMS, ICD-10 codes reported on claims must be supported with clear documentation in the medical records, including an evaluation or assessment, treatment plan, and progress note from an in-person appointment (including telemedicine visits) with an acceptable health care provider.

There are two timelines each year for these CMS-required risk-adjustment record reviews:

  • Medica’s Medicare record review runs from March-June each year.
  • Medica’s commercial/IFB record review runs from June-November each year.

Note: Medica has additional chart-review periods during the year that are not RADv-driven.

Medica notifies provider offices when the records are needed, and appreciates providers’ prompt assistance in response to these data requests.


[Return to top]

Pharmacy News


Effective April 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 April 1, 2018. For certain Medica members, as noted below, these changes would be effective April 1, 2018, for new prescriptions, but not effective until May 1, 2018, for existing prescriptions. The changes to these formularies are now posted online (note that some will remain unchanged).

  • See changes to the 2018 Medica Commercial Large Group Drug List – effective 4/1 for new prescriptions, 5/1 for existing.
  • There are no changes to the 2018 Medica Commercial Small Group Drug List.
  • There are no 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 4/1 for new prescriptions, 5/1 for existing.
  • See changes to the 2018 Medica Over-the-Counter (OTC) Drug List for MHCP.


Effective May 1, 2018:
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 May 1, 2018, 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
J9042 Adcetris brentuximab vedotin
J0178  Eylea aflibercept
J1322 Vimizim elosulfase alfa

These policies will apply to Medica commercial members, individual and family business (IFB) 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). They will not apply to Medica Prime Solution® (Medicare Cost) 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:


Effective May 1, 2018
Upcoming changes to Medica Part D drug formularies

Medica posts changes to its Part D drug formularies on 60 days prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective May 1, 2018. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly.

As of March 1, 2018, view the latest Medicare Part D drug formulary changes.

Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. 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.


[Return to top]

Network News


Effective May 1, 2018:
Medica to update reference lab fee schedule for all products

Effective May 1, 2018, Medica will update the standard reference lab fee schedule for all Medica products in both its metro and regional service areas. The effect on reimbursement will vary by the mix of services provided. Providers who have further questions may contact their Medica contract manager.


[Return to top]

Administrative News


Provider College administrative training topic for March

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
"Provider Re-credentialing and Demographic Updates" (class code: PRD)
This training will go over the process of provider re-credentialing, including when it needs to be done and how this information is communicated from Medica to providers and back. It will also cover how to change provider demographic information used to correctly process claims and display in the provider search tool on Proper provider credentialing and set-up is crucial to ensure correct member benefit interpretation and provider payment. Making sure that a provider is re-credentialed in a timely manner helps to eliminate gaps in provider status that cause claims to incorrectly process as out-of-network. Verifying and updating provider demographics also ensures that claims pay properly, plus allows members to make informed, accurate decisions about which providers they see and understand the amounts they should pay.

Class schedule
Class code Topic Date Time Notes
PRD-WM Provider Re-credentialing and Demographic Updates March 20 10-11 am Class code with "WM" means offered via webinar in March

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.

IFB claim appeals: electronic submission now available

Medica has developed a new online capability for providers to electronically submit supplemental documentation related to certain claim appeals. Specifically, this process improvement is a secure submission step for Medica individual and family business (IFB) claims that have been denied.

This electronic submission option is currently only 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 can now scan these documents, save the files to a desktop or hard drive, and then attach them to a new secure electronic form. This is accessible by selecting the “group/policy #IFB” option on Medica’s Claim Adjustment or Appeal Request Form or directly by selecting “Claim Adjustment or Appeal Request” after logging in to Medica’s secure portal.

As a reminder, providers can continue to use traditional appeal avenues for Medica IFB claim denials, either by mail or fax, as needed. And for all Medica claims other than IFB, providers need to continue using mail or fax to submit documentation related to claim appeals.

(Update to "New electronic submission of documents for IFB claim appeals" article in the December 2017 edition of Medica Connections.)


Coding reminder:
Using correct coding for a cancer diagnosis

Cancer is the #3 diagnosis used in the United States. With improved treatment options, more people are surviving cancer. It can be challenging to remember when to use an active treatment diagnosis vs. a history-of-cancer diagnosis. Based on a review of medical records, Medica is seeing inconsistent coding reported for Medica members.

Correct reporting of a cancer diagnosis requires the determination of whether the patient’s cancer is currently being treated or has been eradicated, and documentation to reflect this. The ICD-10 coding system greatly increases the specificity of the cancer code classifications to accurately indicate the diagnosis. For each site of a cancer diagnosis, there are six possible code categories based on the cancer in question:

  • Malignant – primary
  • Carcinoma in situ (CIS)
  • Uncertain behavior
  • Malignant – secondary
  • Benign
  • Of unspecified nature

Current cancer
Active treatment for patients with cancer should be reported with the malignant cancer code corresponding to the affected site. This applies even when a patient has had cancer surgery but is still receiving active treatment for the disease. Current or active treatment means an additional surgery is needed for the malignancy, or the patient is getting radiation therapy, or the patient is receiving chemotherapy directed to that site.

Antineoplastic medications for breast cancer such as Tamoxifen or Femara should be associated by code to an active malignant neoplasm as long as cancer patients are taking the medications.

Personal history of cancer
“Personal history” codes for a cancer diagnosis, Z85.xx, should be used in the following situations:

  • A primary cancer has been previously excised or eradicated from its site.
  • There is no further treatment of the cancer directed to that site and there is no evidence of any existing primary cancer.
  • The code indicates the former site of the cancer.

Diagnosis code Z08.xx is used for a yearly follow-up exam after a completed treatment for malignant cancer, when it’s determined that there is no evidence of recurrent or metastatic cancers and no ongoing treatment underway. For billing, the Z08 code is followed by a second code indicating the history or type of cancer.


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
Made regulatory updates to requirements for Medicare and Minnesota Health Care Programs by revising “Government Access to Records” and adding “Screening and Enrollment” and “Overpayments” requirements; also, relocated definitions for “Medicare Advantage Special Needs Plans,” “Primary Care Clinic” and “Primary Care Physician” “Special Contracting Requirements” section, in “Government Program Requirements” subsection, under “Provider Requirements for Medicare and Minnesota Health Care Programs” February 2018
(effective 1/1/18)
Added 2018 DHS contracts “Special Contracting Requirements” section, in “Government Program Requirements” subsection, under “Medica Contracts with Minnesota Department of Human Services (DHS)” February 2018
(effective 1/1/18)

For the current version, providers may view the Medica Provider Administrative Manual online.


[Return to top]

SelectCare/LaborCare News


Latest UHC provider bulletin available online

UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (February 2018). Highlights that may be of interest to LaborCare® network providers include:

  • Billing issue identified for IVIG and Remicade® claims without appropriate diagnosis codes, as submitted by outpatient facilities
  • Short-acting opioid supply and daily dose limits for patients new to therapy — scheduled for March 2018
  • Change in obtaining medications BrineuraTM, Durolane® — scheduled for May 2018
  • Procedure to Modifier Policy to be revised, requiring anatomical modifiers — scheduled for May 2018

View the February 2018 UHC provider bulletin.

[Return to top]

Posted: February 21, 2018

Date: 9/27/2021 8:27:16 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02