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Provider Medica Connections

April 2018

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

General News

Effective April 1, 2018:
Medica offers new 'Signature Solution' Medicare Supplement

Medica is now offering a new Medicare Supplement product called “Medica Signature Solution℠” in all 87 Minnesota counties, with coverage effective beginning April 1, 2018. A Medicare Supplement is a private health insurance policy that supplements original Medicare benefits, covering “gaps” like deductibles, coinsurance, and copayments for Medicare-covered services. Medicare pays the first share of Medicare-approved claims, then the Medicare Supplement policy pays its share. Members must be enrolled in Part A and Part B original Medicare and must pay a Medicare Supplement policy premium as well as their Part B premium. Medica Signature Solution includes Basic and Extended Basic plan options.

Members who have a Medicare Supplement plan have the choice to see any U.S. provider that accepts Medicare assignment. No referrals or prior authorization are needed. Members must purchase a Medicare Part D drug plan separately.

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


CMS changes Medicare ID numbers; new cards mailing soon

The Centers for Medicare and Medicaid Services (CMS) will soon start mailing out new ID cards for Medicare beneficiaries. The cards have a unique new Medicare number to replace the Social Security number on the cards. The new Medicare cards do not replace cards for Medicare coverage from private health plans like Medica. The new Medicare number is needed to join, leave or switch to a different plan, although the new Medicare numbers won’t change Medicare benefits. Medicare beneficiaries may start using their new card as soon as they get it.

For more details, including next steps to ensure that provider offices as well as patients are ready for the new Medicare ID cards, refer to CMS.


Medica Foundation announces provider grant recipients
2017 core mission support grants total $200,000

The Medica Foundation has concluded its organizational core mission support funding, awarding grants totaling $200,000 to 40 nonprofit agencies. Grants were awarded to support health-related programming essential to nonprofit missions at organizations in the regional and rural areas of the Medica Foundation’s service area, which includes Minnesota, western Wisconsin, North Dakota and South Dakota. Selected organizations operate outside the Twin Cities metro area and are dedicated to supporting the health of those they serve.

The following providers were among the recipients of core mission grants of up to $5,000 each:

  • Duluth Lighthouse for the Blind (Duluth, Minn.) – to strengthen the social and emotional support for seniors experiencing vision loss.
  • HealthFinders Collaborative (Northfield, Minn.) – to contribute to salaries of front-line care staff in the care coordination program.
  • Just Kids Dental Incorporated (Two Harbors, Minn.) – to supplement registered dental hygienist salaries and purchase dental supplies.
  • Knute Nelson Foundation (Alexandria, Minn.) – to launch the first telemedicine program with Struthers Parkinson’s in the state of Minnesota to offer follow-up visits with clients and their physicians.
  • Lutheran Social Service of Minnesota (St. Cloud, Minn.) – to provide emergency child care, donations of child care supplies and home visits through the St. Cloud Crisis Nursery.
  • Northern Dental Access Center (Bemidji, Minn.) – to contract with a new dental school graduate to reduce the wait time for treatment.
  • Valley Community Health Centers (Grand Forks, North Dakota) – to purchase prescription glasses and offer social-worker support to those experiencing vision loss.
  • Women’s Health Center of Duluth (Duluth, Minn.) – to purchase medical supplies and pay for staff salaries.

“Health care is going through a period of change,” said JoAnn Birkholz, director of the Medica Foundation. “We remain committed during these challenging times through support of our partners who improve health and remove barriers to health care services for those in need.”

In total for 2017, the Medica Foundation awarded $1.2 million to 87 nonprofit and government agencies. Details about grant recipients, funding opportunities, giving guidelines and application deadlines are available online at


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Clinical News


Effective May 21, 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 May 21, 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 May 21, 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 April 2018 for policies that will be changing effective June 18, 2018. These upcoming policy changes will be effective as of that June date unless otherwise noted.


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

Medica requires its Minnesota-based network providers to submit first-quarter 2018 quality-of-care complaint reports to Medica by April 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

CMS requires Medicare enrollment to prescribe Part D drugs

As a reminder, providers who prescribe Part D drugs for Medicare patients need to enroll in or validly opt out of Medicare so their Medicare patients avoid any delays in obtaining prescribed drugs. This enrollment step is required by the Centers for Medicare and Medicaid Services (CMS).

All prescribers must be enrolled by January 1, 2019, to ensure that Part D enrollees continue to get their prescriptions. CMS encourages all providers who prescribe Part D drugs to enroll in this Medicare program now, if they have not already done so. Effective as of January 1, 2019, Medicare Part D may no longer cover drugs that are prescribed by physicians or other eligible professionals who are neither validly enrolled nor opted out of Medicare.

Part D prescribers include physicians, dentists, psychiatrists, residents, nurse practitioners and physician assistants who prescribe drugs for Part D patients, including those in Medicare Advantage plans. For more information, including how to enroll, visit the CMS Part D Prescriber Enrollment website.

Effective June 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 June 1, 2018. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly.

As of April 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.

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Administrative News


Provider College administrative training topic for April

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-WA Life of a Claim April 17 10-11 am Class code with "WA" means offered via webinar in April

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 June 1, 2018:
Special transportation services: online-only submission

Beginning on June 1, 2018, health care providers will be required to submit the Certification of Need form for special transportation to Medica electronically, using Other methods of form submission will no longer be accepted. The Certification of Need form is needed to refer Medica’s members in Minnesota Health Care Programs (MHCP) for special transportation services. Medica’s MHCP products are:

  • Medica DUAL Solution® – for Minnesota Senior Health Options (MSHO) enrollees
  • Medica Choice CareSM – for Minnesota Senior Care Plus (MSC+) enrollees
  • Medica AccessAbility Solution® – for Special Needs Basic Care (SNBC) enrollees

This change is consistent with the current direction for the exchange of health care information in the state of Minnesota. Electronic submission of Certification of Need forms allows Medica to have consistent and comprehensive data from providers. It can be used to help detect fraud, waste and abuse, as well as for quality-of-care purposes. Learn more about special transportation for MHCP members.


Effective June 1, 2018:
Certain specialty claims to undergo ‘Focused Claims Review’

Beginning with June 1, 2018, dates of processing, Medica will implement a new program to review health care claims for certain specialties prior to payment. This “Focused Claims Review” program will be administered by OrthoNet, an orthopaedic specialty benefit management company. OrthoNet’s team of board-certified physicians reviews claims and records to verify accurate coding for billed services. This new claim-review program will initially apply only for Medica members of select commercial groups.

The steps in this new process include:

  • High-cost and atypical professional claims are targeted for focused review pre-payment.
  • OrthoNet reaches out to provider offices for supporting documentation. Records can be returned by fax or mail.
  • Same-specialty physicians review the claims and records.
  • Claims are sent for accurate payment, adjustment or denial.

Providers have up to 30 days to submit supporting documentation for claims, after which the claims may be denied. Provider remittance advices (PRAs) will indicate the outcome for affected claims.

These are the initial specialties included in this new program starting June 1:

  • Anesthesiology
  • Cardiology
  • Chiropractic
  • Dermatology
  • ENT
  • General surgery
  • Hand surgery
  • Neurological surgery
  • Neurology
  • Orthopedic surgery
  • Pain management
  • Physiatry (physical medicine & rehabilitation)
  • Plastic surgery
  • Podiatry
  • Sports medicine
  • Urology

Providers will continue to have the ability to appeal payment decisions; OrthoNet will handle these appeals. Physicians can also call OrthoNet for a peer-to-peer discussion of appeals.

OrthoNet’s care management model helps ensure the delivery of high-quality, cost-effective care while realizing substantial savings that keep the cost of health care down.


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 (March 2018). Highlights that may be of interest to LaborCare® network providers include:

  • Opioid management program enhancements now in effect.
  • Laboratory Services Policy to be revised — scheduled for June 2018.
  • Multiple procedure payment reduction for diagnostic cardiovascular procedures to be revised with Global Test Only codes — scheduled for June 2018.
  • New prior authorization requirement for Xgeva (denosumab) — scheduled for June 2018.
  • New prior authorization requirement for Sublocade — scheduled for July 2018.

View the March 2018 UHC provider bulletin.

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Posted: March 28, 2018

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