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.
Reporting FormsQuarterly Quality Complaint Reporting: 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
Medica’s Provider Administrative Manual, Chapter 14, Section B, Subsection 3.
Refusal of Care: 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. Providers should reference
Medica’s Provider Administrative Manual, Chapter 14, Section B, subsection 4, for more information on the provider refusal of care process.
For more information on other coding, claims, reimbursement or general forms and/or processes, please visit
Tools and Forms.
1 NCQA® is a registered trademark of the National Committee for Quality Assurance, Inc.