The forms and processes below are intended for Medica network providers to use in responding to reporting obligations required by law, contract or accreditation standards (including those required by the 1 National Committee for Quality Assurance, or NCQA®). These forms and processes do not necessarily constitute an all-inclusive list. However, Medica wants providers to be aware of the important reporting obligations related to them.
Topics on this page:
Disclosure of Ownership, Transactions and Excluded Entities
Quality Complaint Reporting
Termination of Health Services by a Provider
Additional Resources
Initial Responses due August 14, 2009:
The Minnesota Department of Human Services (DHS) requires Medica to ensure that its network providers meet certain obligations pertaining to disclosure of ownership interests and transactions. These requirements are summarized below, along with the process for submitting this information to Medica on a new Disclosure Statement form.
Note: Providers must complete and submit the initial Disclosure Statement form by August 14, 2009, whether or not they have information to report.
Disclosure of ownership interests
By August 14, 2009, providers need to initially report to Medica the following information related to ownership interests:
- The name and address of each person with an ownership or control interest in the provider, or in any subcontractor in which the provider has a direct or indirect ownership of 5 percent or more;
- A statement as to whether any person with an ownership or control interest is related as a spouse, parent, child, or sibling to any other person with an ownership or control interest; and
- For a person with an ownership or control interest in the provider, the name of any organization in which the person has an additional ownership or control interest.
This disclosure stems from requirements by the Centers for Medicare and Medicaid Services (CMS). See more on requirements for this disclosure.
Disclosure of transactions
Also by August 14, 2009, providers need to initially report to Medica the following information related to transactions:
- The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the previous 12 months; and
- Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the previous five years.
This disclosure stems from CMS Program Integrity Requirements, created to combat Medicaid provider fraud and abuse. See more on requirements for this disclosure.
For providers to submit the information outlined above, Medica has a new Disclosure Statement form available. Again, providers must complete and initially submit this form by August 14, 2009, whether or not they have information to report.
Print the new Disclosure Statement form.
Where to send your forms for the above requirements:
There are three ways to return forms to Medica.
Mail Route CW210
P.O. Box 9310
Minneapolis, MN 55440-9310
The Minnesota Department of Human Services (DHS) requires Medica to ensure that its network providers meet certain obligations pertaining to individuals and entities excluded from government programs. This requirement is outlined below, along with the process for submitting this information to Medica.
Providers are required to follow these steps:
- Search the Medicare Exclusion Database (MED) or the Office of Inspector General List of Excluded Individuals/Entities (LEIE) database monthly to ensure that no providers, agents, persons with an ownership or control interest, and managing employees (general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operations of an institution, organization or agency) are excluded from participation in Medicaid, Medicare, or other federally funded government healthcare programs in accordance with the Social Security Act, and that they have not been convicted of a criminal offense related to involvement in such programs;
- Assure Medica that no agreements exist with an excluded individual or entity for the provision of items or services related to Medica's obligations under its contract with DHS or CMS; and
- Report to Medica within five days any information regarding individuals or entities who have been convicted of a criminal offense related to the involvement in any program established under Medicare, Medicaid, or other federally funded government healthcare programs in accordance with the Social Security Act, or that have been excluded from participation in such programs.
From the U.S. Department of Health and Human Services, providers are able to:
Providers can submit this information to Medica using a new Disclosure Statement form available. This is the same form used for ownership and transaction disclosure requirements, as outlined in the article above.
Print the new Disclosure Statement form.
Where to send your forms for the above requirements:
There are three ways to return forms to Medica.
Mail Route CW210
P.O. Box 9310
Minneapolis, MN 55440-9310
The state of Minnesota requires health plans to ensure that providers report all quality complaints received at the clinic level to the enrollee’s health plan. (Minnesota Statute 62D.123, Subd. 2 and Minnesota Rules 4685.1110 Subp.9) Complaints directed to the medical group are to be investigated and resolved by the medical group. Providers will also cooperate with Medica to resolve such complaints from members. Quality complaints are defined as concerns regarding access to services, communication/behavior, coordination of care, technical competence, and appropriateness of services affecting patient safety or comfort.
At a minimum, medical groups must provide a written report to Medica Health Plans Quality Improvement Department on a quarterly basis. Please submit by the second Friday following the end of each quarter.
Reporting is required even if no complaints are received during the quarter. Please see the Member Complaints section of your provider agreement, as well as the Complaint Review Process.
View Complaint Review Process.
Download Quality Complaint Reporting Form.
The state of Minnesota (Minnesota Rules 4685.1010, subpart 2.H) requires that health plans ensure the appropriate handling of situations when a network provider refuses treatment to a member.
If a Medica network provider refuses to continue providing health care services to a member, the provider must notify Medica of his/her intention to discontinue treating the member. For more information on the provider refusal of care process, providers should
reference Termination of Health Services by a Provider.
For more information on other coding, claims, reimbursement or general forms and/or processes,
visit Tools and Forms.
1 NCQA® is a registered trademark of the National Committee for Quality Assurance, Inc.
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