Although every effort is made to ensure accurate claim processing, occasionally a claim (or group of claims) may be processed incorrectly. It then becomes necessary to adjust the claim(s). A claim may need to be adjusted when:
- The provider is underpaid or overpaid
- The wrong provider is reimbursed
- Medica's claim audit procedure uncovers an error
- Medica’s staff receives new information about a claim or the agreement under which it was processed
The need for a claim adjustment can be determined by either the provider or Medica. Typically, Medica performs necessary adjustments without requesting additional information from the participating provider.
The provider will see the adjustment on the Provider Remittance Advice.When participating providers identify the need for claim adjustment(s) that are permissible within the time frames outlined in their Medica Participation Agreement or when information differs significantly from the original claim submitted, the provider should complete an Adjustment Request Form and send it to Medica at the address listed on the request form. A copy of the Provider Remittance Advice may be attached to expedite the adjustment.
Download Adjustment Request Form.
Requests for claim adjustments on
underpayments or
overpayments must be made within
180 days from the reimbursed date. Medica will accept late or additional charges associated with such claims if made within
60 days from receipt of the initial claim.
Adjustments may be made to any previous claim reimbursement when Medica determines through the Special Investigations Unit’s (SIU) investigative process that a provider was either underpaid or overpaid as a result of erroneous, abusive or fraudulent billing.
Upon completion of an investigation by the SIU, Medica may make adjustment within
six years from the reimbursed date of the claim following full disclosure to the provider of the nature of the adjustment and extent to which the adjustment will be made.
A participating provider may dispute any finding of overpayment through the dispute resolution procedure set forth in the Medica Participation Agreement.
Providers are able to obtain additional information, including downloadable forms, under the Adjustment and Resubmission Processes section of
Claims Tools and Forms.Return to Administrative Policies and Procedures.