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confidential service is any service provided for a patient age 12 or older. Medica’s claim processing system identifies services strictly by age, not procedure or diagnosis code.
When a confidential service has been identified in the Medica Claim Department:
For participating providers: Explanations of Benefits (EOBs) are not system-generated and are not sent to members. If a member calls to request an EOB for coordination of benefit purposes, one will be mailed to the home addressed to the patient if age 12 or older.
For nonparticipating providers: EOBs are sent on all claims with member liability. If the member is age 12 or older, the EOB is addressed to the member. If reimbursement has not been assigned to the provider and benefits are an eligible expense, reimbursement is sent to the subscriber with a generic EOB. A detailed EOB (without the check) is still sent to the member.
Even when EOBs are sent, the descriptions are general, not specific to the service. For example, if a member had an abortion, the Current Procedural Terminology (CPT-4) for the procedure falls into the range of 38100-64999. The EOB would read “surgical
service.”
Self-insured groups have the option of having EOBs generated for all services, participating provider and nonparticipating provider claims. Although Medica does not encourage this option, it is available for self-insured groups. Currently, Medica only has a few groups that have elected this option. Minors are still protected.
Learn more about member confidentiality.
Return to Regulatory Reporting.