To ensure timely and accurate reimbursement, the hospital must notify the Provider Commerce: Provider Data Team:
- Prior to a schedule admission of a member. Please refer to your Medica Participation Agreement, notification of admission, for all requirements.
- Within 24 hours of an emergency admission (or the next business day if the admission occurs on a weekend).
The Provider Commerce: Provider Data Team can be notified by:
- Calling 1-800-458-5512 (option 1, option 4)
- Faxing admission information to 952-992-3555
Mental health/substance abuse admissions can be arranged by:
- Calling Medica Behavioral Health at 1-800-848-8327.
- Select Care and LaborCare enrollees should refer to the phone number on their identification cards.
The member is responsible for notifying Medica of an emergency confinement at a nonparticipating facility as soon as it is reasonably possible by calling the Member Service number on the back of the Medica identification card.
Case managers may review out-of-network emergency health services received by a member and work with the attending physician to determine if and when it is medically appropriate to transfer a member to a participating facility.
These services are excluded from coverage under
in-network benefits:
- Nonemergency care from nonparticipating providers, unless authorization is obtained from Medica Care Management.
- Unauthorized continued confinement in a nonparticipating facility after the attending physician determines it is safe to transfer the member to a participating facility.
- Follow-up care from a nonparticipating provider unless authorization is obtained from Medica Care Management.
Concurrent review documents are the clinical indicators that support ongoing need for hospitalization and most importantly Medica’s proactive involvement in coordination of postdischarge alternative care services when indicated.
Medica collaborates with the interdisciplinary health care team to facilitate an appropriate discharge plan, including but not limited to, home health care, skilled nursing facility (SNF) stay, durable medical equipment (DME) and/or referral to community resources.
- A physician can obtain assistance with discharge planning by calling Medica Care Management at 1-800-448-5512 ( option 1, option 4).
- Case managers work with the hospital’s discharge staff to ensure that discharge needs are met and to prevent any discharge delays.
Medica focuses its review process by conducting reviews for designated admissions based on specific criteria. Coverage approvals are based on the information received through the clinical review process for both concurrent review and discharge planning.