Definitions

Administrative Referral or Referral – permission from a primary care provider/clinic to receive medically necessary care or services from a provider outside of the member’s primary care clinic or care system when such care or services are not available within the primary care clinic.

Standing Referral – a referral issued by a participating provider and authorized by the member’s primary care provider for conditions that require ongoing services from a specialty provider. A Standing Referral will only be authorized for the period of time appropriate to the member’s medical condition.


Medica Products Requiring an Administrative Referral

• Medica Elect^®
• Medica Essential^SM
• Medica Premier^SM
• Medica DUAL Solution-MSHO (Minnesota Senior Health Options)

Providers are able to obtain copies of the product specific referral guidelines under the Referral Process section of Claim Tools and Forms, or by contacting the literature request line at 952-992-2232 or 1-800-458-5512 (option 1, option 4, ext. 2-2355).

Note: These products all require an Administrative Referral to be submitted to Medica prior to a Medica member receiving services and prior to claims submission to ensure reimbursement at the appropriate benefit level.


Referral Guidelines

• A referral request must be authorized in advance by the member’s primary care physician/clinic.
• All referrals must originate from the Medica member’s primary care physician/clinic.
• Approved referrals are valid for the date(s) of service specified on the referral request form.
• All referrals are subject to the member’s Medica eligibility status and plan benefits for the date(s) of service indicated on the referral.
• A referral request is valid for a period not to exceed six months.

If you have questions, call the Medica Provider Service Center at 1-800-458-5512 or e-mail referralinquiry@medica.com.



Return to Administrative Policies and Procedures.