Provider Alert Archive
| Date: 09/04/2009 |
| Description: Limited Availability of Medica Electronic Transactions This Weekend |
Alert: From Friday evening, September 4, to Sunday morning, September 6, there will be limited availability of Electronic Transactions on medica.com due to scheduled maintenance related to the Medica Web site. As a result of this scheduled weekend update, Medica online transactions will only provide limited data such as member eligibility. Medica apologizes for any inconvenience.
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| Action: No action is required. |
| Date: 09/01/2009 |
| Description: Blood Glucose Monitoring Class to be Modified on Medica Formularies |
Alert: Effective January 1, 2010, Medica will remove all Lifescan blood glucose monitoring meters and test strips from both the Medica standard commercial drug formulary and the Medica Choice Care/Medica MinnesotaCare drug formulary (for Minnesota Health Care Programs). The Lifescan meters and test strips that are included in this removal are One Touch Ultramini, One Touch Ultra, One Touch Ultrasmart, One Touch Ultra 2, One Touch Basic, One Touch Ultralink, Fast Take, SureStep, and SureStep Pro.
Effective October 1, 2009, Medica will add Bayer blood glucose monitoring meters and test strips (Breeze 2 and Contour) to the standard commercial and MHCP formularies, which also include the Roche (Accu-Chek) blood glucose monitoring meters and test strips. Medica members currently using Lifescan products will be notified and provided with opportunities to receive an Accu-Chek Aviva, Accu-Chek Compact Plus, Bayer Contour, or Bayer Breeze 2 meter at no charge to assist in this transition.
The above formulary changes will not apply to the Medica Medicare Part D drug formulary.
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| Action: Prescribers of Lifescan blood glucose monitoring systems should consider alternative options in light of the above formulary changes. See information on Medica formularies and Medication Request Forms.. |
| Date: 08/20/2009 |
| Description: Medica Expands Coverage for Bevacizumab (Avastin) |
Alert: Effective with August 19, 2009, dates of service, Medica has modified its coverage of bevacizumab (Avastin®) to include cervical cancer as a covered indication. This change applies for all Medica members.
- Medica now covers bevacizumab for each of the following indications:
- Metastatic colorectal cancer
- Recurrent or metastatic non-squamous, non-small cell lung cancer
- Metastatic breast carcinoma
- Metastatic renal cell carcinoma
- Malignant gliomas
- Metastatic ovarian cancer
- Recurrent or metastatic cervical cancer
- For treatment of all other cancers, bevacizumab continues to be considered investigative and therefore remains not covered. These non-covered conditions include but are not limited to:
- Acute myeloid leukemia
- Hepatocellular carcinoma
- Gastroesophageal junction adenocarcinoma
- Gastric cancer
- Gastrointestinal stromal tumors
- Carcinoma of the pancreas
- Carcinoma of the prostate
- Sarcoma
- Melanoma
- Fallopian tube tumors
- Diffuse large B cell lymphoma
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| Action: As of September 1, 2009, providers can see the complete text of the coverage policy that applies to this determination, "Bevacizumab (Avastin)," under Coverage Policies. |
| Date: 08/10/2009 |
| Description: Disclosure of Ownership, Transactions & Exclusions – Responses Due August 14 |
| Alert: All providers must disclose to Medica certain information pertaining to ownership interests, business transactions, and excluded individuals and entities. This disclosure is needed by August 14, 2009—whether or not providers have such disclosure information to report. Medica wishes to thank providers for their time and prompt attention to this matter. |
| Action: Complete the Medica Disclosure Statement form and submit it to Medica by August 14. This form contains instructions for completing and returning it to Medica. Find more information about this disclosure requirement in the August 2009 edition of Medica Connections, which outlined these reporting obligations. Providers may also call the Medica Provider Service Center at 1-800-458-5512 with related questions. Again, Medica wants to thank providers for their prompt response to this obligation. |
| Date: 08/05/2009 |
| Description: Facility Claims With Pro-Tech Status Indicator 5 Charges Denied Incorrectly |
| Alert: Medica has identified a claims processing error for facility UB-04 claims as of July 1, 2009, that were related to the professional and technical status indicator 5. Facility claims processed in July had these charges inappropriately denied with reason code 223 (“Place of Service Inappropriate for Procedure”). Medica has taken steps to correct this denial error and will reprocess all affected facility claims. Providers should notice adjustments to such claims within 90 days. |
| Action: Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests. For further details on this policy change that was effective July 1, 2009, providers can refer to the related reimbursement policy or the June 2009 edition of Medica Connections. |
| Date: 08/05/2009 |
| Description: C&TC Claims With Code S0302 Incorrectly Denied |
| Alert: Medica has identified a system error for Child & Teen Checkups (C&TC) claims with procedure code S0302—for completed early periodic screening diagnosis and treatment services—that were denied with reason code 059 ("Service Included in Primary Procedure"). This applied to C&TC claims beginning with July 1, 2009, dates of service. This error only affected claims submitted on behalf of Medica Minnesota Health Care Programs enrollees (i.e., Medica Choice CareSM and Medica MinnesotaCare members). Medica has corrected the system error and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days. |
| Action: Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests. |
| Date: 06/23/2009 |
| Description: Growth Hormone Drug Class to be Modified on Medica Formularies |
Alert: Effective July 1, 2009, Medica will remove the following growth hormone medications from the Medica formularies: Genotropin, Humatrope, Nutropin, Nutropin AQ, Saizen, Serostim, Tev-Tropin, and Zorbtive. The following growth hormone agents will continue to be formulary medications for Medica: Norditropin and Omnitrope. This formulary change will not apply to the Medica Part D drug formulary.
Note that this change applies July 1 for new prescriptions only; any Medica members currently taking one of these affected medications will be able to continue taking it at their current benefit level through September 30, 2009. Prescribers are encouraged to use this 90-day transition period to discuss treatment alternatives with affected patients. Medica is directly notifying prescribers and patients who are affected by this change. This modification of the Medica drug formularies was determined after careful consideration of clinical efficacy among current formulary growth hormone medications and finding no substantial clinical differences among them. |
| Action: Prescribers of the above medications should consider alternative medication options in light of this formulary change. See information on Medica formularies and Medication Request Forms. |
| Date: 05/27/2009 |
| Description: Medica Expands Coverage for Intra-articular Hyaluronan Therapy (Viscosupplementation) |
Alert: Effective with May 20, 2009, dates of service, Medica has modified its coverage related to intra-articular hyaluronan therapy (viscosupplementation). This change applies for all Medica members and is as follows.
- Intra-articular hyaluronon therapy is covered for osteoarthritis of the knee and treatment of disorders of the temporomandibular joint (TMJ).
- Coverage is limited to the following products: Synvisc®, Euflexxa™, and Synvisc-One™ (Synvisc-One is newly added).
- Intra-articular hyaluronon therapy for osteoarthritis of other joints — including but not limited to hip, shoulder, ankle or hand/thumb — is considered investigative and is therefore not covered.
- Medica does not cover the following products: Hyalgan®, Supartz®, and Orthovisc®.
Please note that claims received for non-covered intra-articular hyaluronan products will be denied as provider liability while claims received for any indications that are not covered will be denied as member liability. |
| Action: Providers can see the complete text of the coverage policy that applies to this determination, “Intra-articular Hyaluronan Therapy (Viscosupplementation),” under Coverage Policies. |
| Date: 05/11/2009 |
| Description: Medica Continues to Reward Healthcare Innovation With $25,000 Award |
Alert: Medica is currently offering a second-annual innovations award, called "Raising the Bar: Rewarding Innovation in Healthcare Value." One or more of these awards will be presented in fall 2009 in an amount of at least $25,000 each. Medica wants to recognize the work of provider groups undertaking unique changes to improve quality and decrease healthcare costs with proven results. The "Raising the Bar" award for 2009 continues to recognize the provider community's work in defining healthcare excellence.
Any provider group, clinic or facility that administers patient care in the Medica provider network is eligible for this award. The deadline for award applications is June 30, 2009. Complete details, including the award application, are available online. |
| Action: Providers are encouraged to submit applications soon. Find out more. |
| Date: 05/01/2009 |
| Description: Tamiflu and Relenza added to Medica Formularies |
| Alert: Effective May 1, 2009, antiviral drugs Tamiflu (oseltamivir) and Relenza (zanamivir) have been added to Medica’s List of Preferred Drugs based on Centers for Disease Control and Prevention (CDC) guidelines. Tamiflu and Relenza are medications indicated for the treatment and prophylaxis of influenza. Both of these medications have been shown to be effective against the H1N1 (swine influenza) virus. This formulary change applies to all Medica drug formularies, other than the Medica Part D formulary, which currently covers both of these medications. Existing quantity limits per prescription will remain in effect. Medica members will now be able to get these two drugs at their preferred drug benefit level — typically with a copayment for a brand-name drug. |
| Action: See Medica formulary information. Refer to the CDC for further details about swine flu. |
Updated 04/20/2009
Date: 04/03/2009 |
| Description: Medica, Aetna, UnitedHealth Group Modify Policies for Flooded Areas |
| Alert: Medica, Aetna and UnitedHealth Group have taken steps to ensure that the healthcare needs of their local members (Medica members, SelectCare enrollees and LaborCare enrollees, respectively) are being met during the recent Red River Valley flooding in North Dakota and Minnesota. Area residents have experienced hospital evacuations, clinic closings and other flood-affected operations. Part of the health plans' contingency planning related to the flooding includes making sure that providers continue to get paid for their services. |
Action: Please refer to the attached notifications from Medica, Aetna and UnitedHealth Group.
Update (04/20/2009): Aetna and UnitedHealth Group Extend Flood-Related Policies Through April 24, 2009 |
| Date: 04/13/2009 |
| Description: New EPS electronic transaction now available through Medica.com |
Alert: Providers can now see electronic payments and statements (EPS) for certain claims -- i.e., those processed on the new business platform. This capability is now listed as a new electronic transaction at Medica.com. The EPS enhancement will allow providers to:
- set up electronic transfers so Medica can direct deposit funds to a provider’s bank account; and
- see payment records online, such as EOB statements (with claims payment information grouped by tax ID number) or electronic provider remittance advice (EPRA) 835 transactions.
The Primary Administrator for each provider organization will need to delegate access to this new transaction for billing offices and others to see banking and payment details online. Providers will need to enroll online for each of their organization’s tax ID numbers. A user’s guide and other information are available online when providers access the EPS landing page. Again, EPS functionality is available for claims processed using the new business platform only. As a result, this capability will only apply to a small set of Medica claims at this time. However, this may be expanded in the future. |
| Action: Providers can begin using EPS immediately. Access it at the Electronic Transactions secure web page. Providers with questions may call the Medica Provider Service Center at 1-800-458-5512. |
| Date: 04/03/2009 |
| Description: Medica, Aetna, UnitedHealth Group Modify Policies for Flooded Areas |
| Alert: Medica, Aetna and UnitedHealth Group have taken steps to ensure that the healthcare needs of their local members (Medica members, SelectCare enrollees and LaborCare enrollees, respectively) are being met during the recent Red River Valley flooding in North Dakota and Minnesota. Area residents have experienced hospital evacuations, clinic closings and other flood-affected operations. Part of the health plans' contingency planning related to the flooding includes making sure that providers continue to get paid for their services. |
| Action: Please refer to the attached notifications from Medica, Aetna and UnitedHealth Group. |
| Date: 04/02/2009 |
| Description: Medica to Change Approval Process for HHA Services |
| Alert: As a reminder, effective with May 1, 2009, dates of service, Medica will modify its process for home health aide (HHA) requests. This change applies for all Medica members. Medica will require a prior authorization for payment of HHA services. Providers will need to submit a prior authorization request either by working with the member's care coordinator for state programs dually funded by Medicare and Medicaid or through the Medica standard prior authorization process. It is the responsibility of HHA agencies to provide services in accordance with each authorization, which is expected to be obtained prior to the date of service. Effective May 1, if an HHA agency fails to obtain prior authorization for services, related claims may be denied as provider liability. |
| Action: As of May 1, 2009, providers will need to follow the new Medica process for requesting HHA services. For more details on this process change, see the March 2009 edition of Medica Connections. |
| Date: 03/20/2009 |
| Description: Medica Expands Coverage for Rituximab (Rituxan) |
Alert: Effective with March 18, 2009, dates of service, Medica has modified its coverage for rituximab (Rituxan®). This change applies for all Medica members and is as follows.
- Coverage for rituximab (Rituxan) has been expanded so that Medica now covers it for each of the following indications:
- Autoimmune hemolytic anemia
- B-cell neoplasms (e.g., B-cell non-Hodgkin's lymphoma)
- Evans syndrome
- Immune/idiopathic thrombocytopenic purpura
- Myositis
- Recurrent, relapsed, or refractory Hodgkin's lymphoma
- Systemic lupus erythematosus
- Waldenstrom's macroglobulinemia
- Wegener's granulomatosis
- Chronic lymphocytic leukemia
- Rheumatoid arthritis
- The following indications continue to be considered investigative and therefore remain not covered:
- All other malignancies, including but not limited to solid tumors, acute lymphocytic leukemia, myeloid leukemia, and multiple myeloma.
- Graft-versus-host disease.
- All other indications, including but not limited to multiple sclerosis.
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| Action: As of April 1, 2009, providers can see the complete text of the coverage policy that applies to this determination, "Rituximab (Rituxan)," under Coverage Policies. |
| Date: 03/20/2009 |
| Description: Medica Modifies Coverage for Light Treatment for Dermatologic Conditions |
Alert: Effective with March 18, 2009, dates of service, Medica has modified its coverage for light treatment for dermatologic conditions. This change applies for all Medica members and is as follows.
- UV phototherapy using a 308nm excimer laser is covered for treatment of psoriasis and vitiligo. It is considered investigative and therefore is not covered for all other indications.
- Laser or intense pulsed-light therapy including but not limited to pulsed-dye laser continues to be considered investigative and therefore remains not covered for treatment of the following dermatologic conditions:
- papulosquamous disorders including lichen planu, pityriasis rosea, and dermatophytosis,
- active acne vulgaris,
- eczema,
- atopic dermatitis, and
- rosacea.
- Ultraviolet phototherapy as a treatment for active acne vulgaris is considered investigative and therefore is not covered.
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| Action: As of April 1, 2009, providers can see the complete text of the coverage policy that applies to this determination, "Light Treatment for Dermatologic Conditions," under Coverage Policies. |
| Date: 01/20/2009 |
| Description: Medica Removes ADHD Drug Age Restriction for Medica MHCP Members |
| Alert: An age restriction on Adderall XR and Concerta was implemented on December 1, 2008, for Medica MinnesotaCare and Medica Choice CareSM members utilizing the Medica MHCP drug formulary. This restriction for these extended-release ADHD drugs — announced in the December 2008 edition of Medica Connections, on p. 9 — limited the use of these two medications to members 23 years of age and younger. Effective immediately, the age restriction on Adderall XR and Concerta will be removed and these products will process as formulary brand medications with no restrictions. |
| Action: No action is required of providers. |
| Date: 01/13/2009 |
| Description: Medica to Implement New Denial Code Related to NPI, Effective 3/1/09 |
| Alert: Effective with March 1, 2009, dates of service, Medica will be implementing a new denial code related to the national provider identifier (NPI) number. Denial reason code 991 ("Missing or invalid NPI") will be used for claims that are denied for lack of an NPI. |
Action: To avoid denial of claims, providers will need to submit their NPI number on all claims submitted to Medica. If providers have not already registered their NPIs with Medica, the submission options are as follows. Providers who prefer to send NPI update files via secure file transfer (FTP) should contact Cheryl Wilson at 952-992-2652, by e-mail at cheryl.wilson@medica.com or by fax at 952-992-3270 to exchange file address information. Providers who prefer to send NPI update information via CD or paper should mail the information to:
Medica
c/o Cheryl Wilson
Mail Route CP445
PO Box 9310
Minneapolis, MN 55440-9310 For more NPI submission details, please refer to the August 2008 Medica Connections (pp. 15-16). |
| Date: 11/24/2008 |
| Description: Billing error identified for hemoglobin values on electronic ESA claims |
| Alert: Medica has identified a system limitation that will not allow a provider to bill hemoglobin (Hgb) values electronically, resulting in a denial with reason code 913 ("Additional information needed to process"). Currently, the value for Hgb is not able to be recognized. This issue affects claims for erythropoiesis-stimulating agents (ESAs) Aranesp, Epogen and Procrit for all Medica products. |
Action: Providers who submitted the Hgb value electronically using qualifier R1 should resubmit their claim either on a paper CMS-1500 claim form, reporting the Hgb value in box 24, or electronically with the hematocrit (Hct) value reported. Providers who have questions about electronic claims submission may want to contact their EDI software vendor.
For claims submitted electronically (using the 837 transaction), the Hct value is reported via the 837P (professional claim transaction) in loop 2400, segment MEA, data element MEA03. The MEA segment should be reported as follows:
- MEA01 = qualifier "TR", meaning test results
- MEA02 = qualifier "R2", meaning Hct
- MEA03 = Hct test result
Example: MEA*TR*R2*30 (where 30 is the Hct value)
Providers can refer to the related Medica coverage policy for darbepoetin alfa (Aranesp) and epoetin alfa (Epogen, Procrit) for further information. |
| Date: 10/31/2008 |
| Description: Process Change for Herceptin Claims |
| Alert: To process claims related to trastuzumab (Herceptin), Medica no longer requires submission of a pathology report documenting HER2 overexpression in breast cancer patients. This is a process change only and does not change the related coverage policy effective as of August 1, 2008. Following a review of Herceptin claims since August 1, 2008, Medica has determined that Herceptin is being prescribed appropriately for the treatment of breast cancer. The Medica coverage policy for trastuzumab (Herceptin®) is available in the "Providers" section, under "Clinical & Quality Resources," then "Medical Policies," under "Coverage Policies." |
| Action: Effective immediately, providers do not need to submit pathology reports for Herceptin claims. |
| Date: 10/27/2008 |
| Description: Medica Expands Coverage for Oncotype DX Treatment |
Alert: Effective with October 15, 2008, dates of service, Medica has modified its coverage for gene expression profiling assays for predicting breast cancer recurrence risk. This change applies for all Medica members. Oncotype DX™ breast cancer assay is covered for patients with recently diagnosed breast cancer when:
- The tumor is stage I or stage II, and
- The tumor is estrogen receptor positive, and
- The patient is axillary-node negative, and
- The patient is a candidate for hormone therapy (e.g., tamoxifen).
There is no change for other indications included in Medica’s policy: Oncotype DX breast cancer assay continues to be considered investigative and therefore remains not covered for all other clinical presentations and conditions. |
| Action: Medica will retroactively review related claims and adjust them as necessary. As of November 1, 2008, providers can see the complete text of the coverage policy that applies to this determination ("Gene Expression Profiling Assays for Predicting Breast Cancer Recurrence Risk") under Coverage Policies. |
| Date: 10/27/2008 |
| Description: Claims Denied Inappropriately for ESA Drugs |
Alert: Medica commercial and Medicaid claims for erythropoiesis-stimulating agents (ESAs) Aranesp, Epogen and Procrit -- with dates of service from July 1, 2008, through October 17, 2008 -- were inappropriately denied due to an error in converting hematocrit values to hemoglobin values. This error has been corrected and the related Medica coverage policy for darbepoetin alfa (Aranesp) and epoetin alfa (Epogen, Procrit) will soon be revised and posted under Coverage Policies.
Medica has taken steps to correct this situation by reprocessing all affected claims. Providers should notice adjustments to such claims within 60 days. |
| Action: No action is needed at this time. Medica will reprocess affected claims as necessary, so providers do not need to submit adjustment requests. |
| Date: 10/23/2008 |
| Description: Medica to Update its Drug Formulary for MCHP Members |
| Alert: Effective December 1, 2008, several medications will be removed from Medica's drug formulary for Minnesota Health Care Programs (MCHP) enrollees (i.e., Medica Choice Care and Medica MinnesotaCare members). In addition, new quantity limits for antipsychotic medications, age restrictions for ADHD medications, and step therapy for leukotrienes will also be required for MHCP enrollees. Medica is notifying affected members about these changes. These members with existing prescriptions will have a 90-day transition period beyond December 1 to discuss medication options with their physician. |
| Action: For details, view the MHCP formulary FAQ. There will also be an overview about these changes in the December 2008 edition of Medica Connections. The full Medica Drug Formulary for Minnesota Health Care Programs will be available online by November 1, 2008, on the "Pharmacy" page. |
| Date: 10/17/2008 |
| Description: PT/OT claims incorrectly denied |
| Alert: Medica has identified a claims system error for physical therapy and occupational therapy (PT/OT) claims submitted with GN, GO, GP modifiers for commercial claims processed on Medica’s new administrative platform between March 1, 2008, and September 30, 2008. These claims were denied with reason code FE (“Incorrect modifier or incorrect modifier usage”). Medica has taken steps to correct this situation by identifying all affected claims for reprocessing. Providers should notice adjustments to such claims within 60 days. |
| Action: No action is needed at this time. Medica will reprocess affected claims as necessary, so providers do not need to submit adjustment requests. |
| Date: 10/13/2008 |
| Description: Medica to Implement FY2009 DRG Changes (This provider alert impacts hospitals only) |
Alert: The Centers for Medicare and Medicaid Services (CMS) published the fiscal-year (FY) 2009 Medicare Severity (MS) Diagnosis-Related Group (DRG) changes in the August 19, 2008, edition of the Federal Register. The final rule for the FY 2009 inpatient prospective payment system can be accessed through the following link: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf.
Medica's claims will be processed in accordance with the FY2009 DRG changes for discharges on or after October 1, 2008, to be consistent with CMS. |
Action: No action is required by providers. Providers will not need to submit claim adjustments as a result of the FY2009 DRG updates. These claims will be processed once Medica's claims system has been updated with 2009 DRG changes, effective November 17, 2008.
Note: Providers who have any questions about this are encouraged to discuss it with their contract manager. |
| Date: 10/7/2008 |
| Description: Claims Denied Incorrectly for DME Services Submitted with RR Modifier |
| Alert: Medica has identified a claims processing error involving HCPCS “A”, “E”, “K”, “L” and “S” codes submitted by durable medical equipment (DME) vendors. Affected claims were inappropriately denied with reason code FE, for using an incorrect modifier. Only claims processed on Medica's new administrative platform were affected. Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days. |
Action: Providers do not need to submit adjustment requests. Medica will have all affected claims reprocessed.
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| Date: 9/2/2008 |
| Description: Claims Denied Incorrectly Due to System Error on 8/29/08 |
| Alert: Medica has identified a claims processing error for hospital and physician claims processed on August 29, 2008. A portion of Medica commercial and Minnesota Health Care Programs claims processed on this date were inappropriately denied with denial reason code 22 ("Not an eligible charge; do not bill patient"). Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days. |
Action: No action is needed at this time as Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests.
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| Date: 8/25/2008 |
| Description: Claims Denied Incorrectly for Hospital and Physician Services |
| Alert: Medica has identified a claims processing error for hospital and physician claims processed on August 13, 2008. All Medica Choice Product claims processed on this date were inappropriately denied with denial reason code 68 (“Your plan does not cover this expense”). Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days. |
Action: No action is needed at this time as Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests.
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| Date: 8/25/2008 |
| Description: 'Insights by Medica' Claims Paid Incorrectly for Hospital and Physician Services |
Alert: Medica has identified a claims processing error for hospital and physician claims with dates of service from January 1, 2008, through July 29, 2008, for services provided to Patient Choice InsightsSM by Medica members. A portion of claims were not reimbursed correctly based on the appropriate fee schedule. The following places of service (POS) were affected by this issue: 21-24 (IP Hosp, Out-PT Hosp, ER and Ambulatory Surgery Ctr.), 26 (Military Treatment Facility), 31 (SNF), 34 (Hospice), 41-42 (Ambulance land & air), 51-53 (IP Psychiatric Facility, Psychiatric Facility – Partial Hospitalization and Community MH Care), 56 (Psychiatric Residential Treatment Center) and 61 (Comprehensive IP Rehabilitation Facility).
This issue did not apply to claims that were billed using the following modifiers: AA, AD, QK, QS, QX, QY and QZ. Medica has taken steps to correct this and will reprocess all affected claims. Providers should notice adjustments to such claims within 90 days. |
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| Action: No action is needed at this time as Medica will have all affected claims reprocessed. Providers do not need to submit adjustment requests. |
| Product Impact: Only Patient Choice Insights by Medica claims are affected by this issue. |
| Date: 8/22/2008 |
| Description: Medica to Update Policy on Avastin to Cover Treatment of Ovarian Cancer |
| Alert: Medica will update its coverage policy on bevacizumab (Avastin®) to also cover bevacizumab treatment when used for metastatic ovarian cancer, effective with September 1, 2008, dates of service. The change is due to this condition no longer being considered investigative. As of September 1, the updated coverage policy will be available online at www.medica.com in the "Providers" section, under "Clinical & Quality Resources," then "Medical Policies," under "Coverage Policies." |
Action: No action is necessary. To bill Medica for this service on or after September 1, providers may use current applicable HCPCS code J9035 (Injection, bevacizumab, 10 mg).
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| Date: 8/21/2008 |
| Description: Claims Denied Incorrectly for Pediatric Behavioral Health Screening |
| Alert: Medica has identified a claims processing error involving CPT code 96110 UC, used for pediatric behavioral health screening. The claims were denying for an inappropriate diagnosis, with denial reason code 478 or OM, when submitted with a preventive diagnosis. The error was identified and the system has been corrected as of August 18, 2008. Medica will be identifying all inappropriately denied claims for reprocessing. Providers should notice adjustments to such claims within 90 days. |
Action: Providers do not need to submit adjustment requests. Medica will have all affected claims reprocessed.
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| Date: 8/21/2008 |
| Description: Claims Denied Incorrectly for Initial Hospital Care of Neonate |
| Alert: Medica has identified a claims processing error involving CPT code 99477, used for initial hospital care of a neonate. The claims were denying for requiring a modifier, with denial reason code 093 or MQ. The error was identified and the system has been corrected as of July 30, 2008. Medica will be identifying all inappropriately denied claims for reprocessing. Providers should notice adjustments to such claims within 90 days. |
Action: Providers do not need to submit adjustment requests. Medica will have all affected claims reprocessed.
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| Date: 8/15/2008 |
| Description: Medica Covers 3 Newly FDA-Approved Vaccines |
Alert: Medica covers the following vaccines, as specified. These immunization drugs were recently approved by the U.S. Food and Drug Administration (FDA).
- Kinrix – On 6/24/08, the FDA approved Kinrix, a combination vaccine that offers protection against diphtheria, tetanus, pertussis, and polio in a single shot. As of the FDA approval date, related CPT code 90696 is eligible for reimbursement for all Medica members.
- Pentacel – On 6/20/08, the FDA approved Pentacel, a combination vaccine that combines diphtheria, tetanus, pertussis, polio and Haemophilus influenza type b (Hib) vaccines into a single shot. As of the FDA approval date, related CPT code 90698 is eligible for reimbursement for all Medica members.
- Rotarix – On 4/3/08, the FDA approved Rotarix, a live, oral, vaccine for use in preventing rotavirus gastroenteritis in infants. Rotarix is a liquid vaccine given by mouth in two doses. As of the FDA approval date, related CPT code 90681 is eligible for reimbursement for Medica members through 12 months of age. Claims received outside this age restriction will be denied as provider liability.
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Action: Providers can bill for these 3 vaccines, as necessary. If you have questions, you can call the Medica Provider Service Center toll-free at 1-800-458-5512.
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| Date: 8/15/2008 |
| Description: Medica's claim processing system is tentatively scheduled to be updated to include the 2009 MS-DRG changes on October 1, 2008 |
Alert: The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2009 Medicare Severity (MS) Diagnosis-Related Group (DRG) changes scheduled for publication in the August 19, 2008, Federal Register. The final rule to the FY 2009 inpatient prospective payment system can be accessed through the following link:
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf
The IPPS inpatient rule includes 999 MS-DRGs for 2009. For 2009 the MS-DRG weights are based on 100 percent to the cost determined MS-DRG values.
Medica’s claim processing system is tentatively scheduled to be updated in mid-November. Although implementation of the 2009 MS-DRG update will occur in November, consistent with CMS, the effective date of implementation will be October 1, 2008. Additional detail regarding the timeline will be provided in the next thirty days.
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| Action: Should this change require an alteration to your reimbursement, your Contract Manager will contact you. |
| Date: 8/15/2008 |
| Description: Medica plans to implement ‘Present on Admission’ requirement for inpatient acute care PPS hospitals for Medicare product claims on October 1, 2008 |
Alert: The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2009 Inpatient Prospective rule on July 31, 2008. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Medicare has been requiring the POA indicator since October 1, 2007. The final rule to the FY 2009 inpatient prospective payment system can be accessed through the following link:
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf
Medica is not requiring the Present on Admission indicator at this time for non Medicare claims. |
| Action: Report the Present on Admission indicator on Medica’s Medicare product claims where Medica is primary starting on October 1, 2008. |
| Date: 8/15/2008 |
| Description: PRA Balancing Issues |
| Alert: Medica has identified a system error involving some types of claim adjustments causing balancing issues on provider remittance advices (PRAs) for claims processed on the Cosmos platform. Some fields, including the “Adjusted amount” and “Provider Totals,” may not balance; however, the check payment amounts are correct. A system fix is scheduled for August 24, 2008. |
Action: No action is needed at this time. Providers do not need to submit adjustment requests.
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| Date: 8/8/2008 |
| Description: Medica to Implement EPRA Enhancements Related to New Administrative Platform |
Alert: Medica will soon implement several enhancements to its electronic provider remittance advice (EPRA) for claims processed on the new administrative platform only. These changes in the HIPAA 835 transaction should improve both convenience and security of EPRAs for providers. The date for these changes is tentatively August 19, 2008. The five scheduled updates are:
- Group/policy numbers will be split into a separate field from the 9-digit member ID number as part of the HIPAA 835 transaction (numbers are currently all combined).
- New remark codes will be used regarding individual claims:
A1 = Claim/Service Denied
16 = Claim/service lacks information which is needed for adjudication
17 = Payment adjusted because requested information was no provided or was insufficient/incomplete
96 = Non covered charge(s)
125 = Payment adjusted due to a submission/billing error(s)
- On the EPRA for institutional claims, the national provider identifier (NPI) for the billing provider will show up under "Servicing Provider NPI."
- For adjusted claims, the HIPAA 835 transaction will reflect the NPI number submitted on the original claim.
- Bulk recovery claims reported in HIPAA 835 transactions will contain the entire patient account number (not truncated) as submitted on the original claim.
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Action: Providers may need to update programming for acceptance of these EPRA format changes. You can get further details about these enhancements online in a related EPRA Enhancements reference document. If you have questions, you can call the Medica Provider Service Center toll-free at 1-800-458-5512.
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| Date: 7/31/2008 |
| Description: E&M Add-On Codes for Prolonged Services and Critical Care Services Inappropriately Denying. |
| Alert: Medica has identified a system error for claims processed since March 2008. Approximately 450 claims across all products have denied inappropriately to date as provider liability with denial reason code 277 ("Claim Has Already Been Processed and Paid"). Medica is investigating the system error and once resolved a report will be run to identify all affected claims for reprocessing. |
Action: No action is needed at this time. Medica will adjust claims as necessary. Providers do not need to submit adjustment requests.
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| Date: 7/11/2008 |
| Description: System Error Causing Inappropriate Denials for Physician Claims Processed on 6/30/08. |
| Alert: Medica has identified a system error for professional claims processed on 6/30/08. A portion of claims processed on 6/30/08 were inappropriately denied using reason denial code 478 ("Diagnosis inappropriate for procedure"). Medica has corrected the system error and will reprocess all affected claims. |
Action: No action is needed at this time. Providers do not need to submit adjustment requests.
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| Date: 6/6/2008 |
| Description: Medica to Reprocess Imaging Claims That Were Incorrectly Denied |
| Alert: Medica has identified a system error related to high-tech imaging claims that were inappropriately denied for lack of notification. This issue applies to Passport from Medica claims processed from February to May 2008 for employer groups excluded from the high-tech imaging requirement. Medica has corrected the system error, is identifying all affected claims, and will reprocess these claims. For providers who have already submitted an appeal related to this issue, note that claims will be identified and reprocessed. Providers should see claim adjustments within 60 days. |
Action: No action needed at this time. Providers do not need to submit adjustment requests.
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| Date: 5/23/2008 |
| Description: Formulary Availability to Change on Epocrates Rx |
| Alert: Beginning June 2, 2008, only Medica Part D formularies will be accessible through Epocrates Rx. Medica commercial and state-sponsored plan formulary remains available through Medica’s Web site and can be downloaded onto a PDA by accessing the Minnesota Council of Health Plans Web site. Clinicians can use these same resources to check drug coverage restrictions (e.g., utilization management) and placement of formulary alternatives, as applicable. These resources, like Epocrates Rx, are free of cost to the user. |
Action: For more information about this change, or to access the Medica formulary online, visit the Pharmacy Resources page.
For PDA downloads of Medica’s commercial and state-sponsored plan formulary, visit http://www.mnhealthplans.org/healthplans/prescrip_drug.shtml
For Medica Part D formularies that remain available on Epocrates Rx, visit http://www.epocrates.com/formulary/online.html.
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| Date: 5/5/2008 |
| Description: Digitek heart drug recalled |
| Alert: Digitek®, used in the management of heart failure and abnormal heart rhythm, was voluntarily recalled recently by its manufacturer. The decision to recall this medication was due to the potential for this drug’s tablets to contain as much as twice the approved level of active ingredient. Medica is notifying Medica members taking Digitek and asking them to contact their doctor or pharmacist as soon as possible before taking their next dose. Medica will no longer allow pharmacies to process Digitek claims.You can find additional information about this recall:
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| Action: Providers are encouraged to discuss this with their patients. |
| Date: 4/22/2008 |
| Description: System error caused inappropriate denials for claims processed on 4/21/08 |
| Alert: Medica has identified a system error for claims processed on 4/21/08. A portion of Medica commercial and Medicare claims processed on 4/21/08 were inappropriately denied with reason code 487 ("Service investigational/experimental"). Medica has corrected the system error and will run a report to identify all affected claims to be reprocessed. |
| Action: No action needed at this time. Providers do not need to submit adjustment requests. |
| Date: 4/9/2008 |
| Description: Correct Code Needed for Billing of Part D Vaccine Administration |
| Alert: Providers should be billing with code G0377 (Administration of vaccine for Part D drug) instead of code 90471 after administering a Part D vaccine such as Zostavax, Gardisil, Varivax, Manictra, Vaqta/Havrx , Twinrx, measles/mumps/rubella MMR, tetanus/diphtheria (TD), etc. -- Code 90471 should only be billed when administering non-part D vaccines. |
| Action: Using correct vaccine code when billing. |
| Date: 4/4/2008 |
| Description: Description Corrected for 251 Disallow/Denial Code on Certain Medicare Claims |
| Alert: This is a follow-up notice to a prior issue. Medica has corrected the description for disallow/denial code 251 applied to claims for the Medicare product Medica Prime Solution. As of 4/4/08, the description of the 251 code has been changed back to the correct code description: "Doesn't meet Medicare LDC/NCD criteria." |
| Action: Again, related claims have been processed correctly, so no further action is required. |
| Date: 3/31/2008 |
| Description: Description Incorrect for 251 Disallow/Denial Code on Certain Medicare Claims |
| Alert: Medica has identified an error to the description for disallow/denial code 251 applied to claims for the Medicare product Medica Prime Solution. Despite this inaccurate description, however, the actual claim denials have been processed correctly. Until 3/14/08, the denial explanation correctly read "Doesn't meet Medicare NCD/LCD Criteria." On 3/15/08, the language changed to "Payment of Medicare Copay/Coinsurance," which is an incorrect description. Medica is working on a resolution to this issue and will send a follow-up notice once it is complete. |
| Action: No action required. |
| Date: 3/14/2008 |
| Description: Hyaluronan injection claims processed incorrectly |
| Alert: Medica has identified a processing error for 2008 HCPCS codes J7321-J7324 & 2007 HCPCS codes Q4084-Q4086. Some claims were denied inappropriately when they should have been processed for payment, where other claims were paid inappropriately and should have been denied. This error started with dates of service from 11-1-07 to current. Medica is currently working to update systems to have these claims process correctly. Once the systems have been updated, all impacted claims will be identified and will be reprocessed accordingly. Providers should notice the adjustment within 90 days. |
| Action: Providers do not need to submit adjustment requests. All affected claims will be reprocessed. |
| Date: 2/29/2008 |
| Description: System error causing inappropriate 022 denials for claims processed on 2/27/08 |
| Alert: Medica has identified a system error for claims processed on 2/27/08. A portion of claims processed on 2/27/08 were inappropriately denied reason 022 (not an eligible charge, do not bill patient). Medica has corrected the system error and will run a report to identify all affected claims for reprocessing. |
| Action: No action needed at this time. Providers do not need to submit adjustment requests.
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| Date: 2/29/2008 |
| Description: Medical Dental Claims Processed Incorrectly |
| Alert: Medica has identified a processing error for American Dental Association (ADA) codes D9220, D9610 and D9612. Claims with these codes were inappropriately denied when they should have been processed for payment under a member’s medical-based dental benefit. This error dates from 10-1-06 to current dates of service. Medica is working to update its claims systems to have these claims process correctly. Once the systems have been updated, all claims affected by this error will be identified and reprocessed accordingly. Providers should notice adjustments within 90 days. |
| Action: Providers do not need to submit adjustment requests. All affected claims will be reprocessed.
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| Date: 12/06/2007 |
| Description: Changes to the 835 transaction. |
| Alert: On 11/17, Medica made changes to the 835 transaction (electronic provider remittance advice) produced from our Cosmos claim payment system. The changes include correcting the calculation of the Allowed Amount reported in the AMT segment using the B6 qualifier to reflect the true allowable amount (including the copayment and physician contingency reserve which may be returned to the provider at a later date), reporting NDC codes in the SVC segment using the N4 qualifier and reporting federal tax withholding in the PLB segment using the IR qualifier. |
| Action: Providers should contact their system vendors to ensure these changes will be accurately reflected within their account posting system. Contact the Provider Service Center for additional assistance at 1-800-458-5512. |
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Updated: 11/8/2007
Date: 10/11/2007 |
| Description: Problems with HIPAA 270/271 online transactions have been resolved for most members. |
| Alert: Medica has corrected certain issues with the HIPAA 270/271 online transactions. When checking eligibility on www.medica.com, providers will now be able to verify copay and coinsurance, out of pocket, and deductible for most Medica members. Product descriptions are also now available, as are primary care clinic (PCC) designations for care system products Elect, Essential, and Focus. However, note that for members whose claims are handled on the new claims administration system, the eligibility transaction will continue to display zeros for copay and coinsurance, out of pocket, and deductible information. |
| Action: If you receive incomplete information, as indicated above, when checking eligibility online, please contact the Medica Provider Service Center at 1-800-458-5512. |
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Update (11/8/2007): The issues with the HIPPA 270/271 online transaction have been corrected. Providers will now be able to use the transactions to check nformation on Primary Care Clinic, address, copay, deductible and out of pocket information.
Update (10/25/2007): The HIPAA 270/271 online transactions will be providing a limited data until further notice. Please note the transaction will display name, date of birth, group number, alt id, coverage start and end dates. Information on Primary Care Clinic, address, copay, deductible and out of pocket information will not be provided. |
| Date: 10/11/2007 |
| Description: Certain CPT codes incorrectly denying with reason code 223. |
| Alert: Medica has identified a system error when CPT codes 94750, 94760, 94761, 94762, 94770 and 94772 were submitted and denied with reason code 223 (“Place of service inappropriate for procedure”). This applies to dates of processing of 09/05/2007 through 10/05/2007. Medica is working to identify all impacted claims and will reprocess accordingly. Providers should notice the adjustment within 90 days. |
| Action: Providers do not need to submit adjustment requests. All affected claims will be reprocessed. |
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| Date: 9/19/2007 |
| Description: Medica IT continues to work on resolving the problem with the HIPAA 270/271 online transactions. |
| Alert: Medica IT continues to work on resolving the problem with the HIPAA 270/271 transactions (eligibility inquiry and response) on www.medica.com. In the meantime, Medica will continue to support the "fall back" mode for HIPAA 270/271 transactions. This option allows for all eligibility transactions to be processed; however, the response will only include effective and expiration dates and not copayment, co-insurance, amount of deductible satisfied, etc. Medica is continuing work to correct this issue, but at this time, there is not an anticipated fix date for the problem to be resolved. Medica will post information on the status of this resolution as it becomes available. |
| Action: If you should need to verify member copay, coinsurance or deductible information, please contact the Provider Service Center at 1-800-458-5512 (this information is available in automated self-service format through this phone line as well). |
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| Date: 8/17/2007 |
| Description: Medica's claim processing system is tentatively scheduled to be updated to include the 2008 MS-DRG changes on October 1, 2007 |
Alert: The Centers for Medicare and Medicaid Services (CMS) published the fiscal year (FY) 2008 Medicare Severity (MS) Diagnosis-Related Group (DRG) changes in the August 1, 2007, Federal Register. The final rule to the FY 2008 inpatient prospective payment system can be accessed through the following link:
http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf
The IPPS payment reforms would restructure the inpatient diagnosis-related groups (DRGs) to account more fully for the severity of each patient’s condition. The rule continues to phase in a change introduced in FY 2007 which would better align payment with the costs of care by using estimated hospital costs, rather than list charges, to establish relative weights for the DRGs.
This year, the rule creates 745 new severity-adjusted diagnosis-related groups (Medicare Severity DRGs or MS-DRGs) to replace the current 538 DRGs.
Medica’s claim processing system is tentatively scheduled to be updated to include the 2008 MS-DRG changes on October 1, 2007. Medica’s system is typically not updated until December due to the need for system programming and testing. However, due to the significant impact of the new rule, Medica plans to implement this update to be aligned with CMS.
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| Action: Should this change require an alteration to your reimbursement, your Contract Manager will contact you. |
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| Date: 8/01/2007 |
| Description: Medica Web Site Navigation Streamlined. |
Alert: Medica’s Web site has a new streamlined look. The content is simply reorganized for providers to find and access it more easily. The main drop-down links are now embedded in the “Providers” home page (http://provider.medica.com/default.aspx), which is now a hub through which all provider-focused content is available. The main change is to the top “navigation” bar for provider information, with a modified menu of seven items. These top-level topics include:
* “Electronic Transactions” — currently the most-used function within Medica’s provider Web pages;
* "Reference Tools and Forms" — A new operations-focused area with resources such as administrative manuals, policies, reference documents, claim-related forms, and tools for credentialing and demographic updates;
* "News You Can Use" — A news-focused category containing past editions of Medica Connections® newsletters as well as Provider Alerts;
* "Clinical & Quality Resources" — A new section that will be home to medical policies, clinical guidelines, prior authorization requirements, the Centers of Excellence program list of approved bariatric facilities, and information about Medica’s clinical and quality-improvement programs. |
| Action: Bookmarks to existing Web pages should continue to work. No action is required. |
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| Date: 7/27/2007 |
| Description: Coding Questions e-mailbox to no longer be available. |
| Alert: After September 4, 2007, the Medica Coding Questions e-mailbox (coding.questions@medica.com) will no longer be available, and the fax line for this resource will also no longer be availabe. Coding questions will need to be reviewed within the individual organization. Medica offers online coding tools, including a table of frequently asked questions for provider use. Inquiries beyond provider staff capabilities may be directed to Medica's Provider Service Center. |
| Action: As an alternative to the Medica Coding Questions e-mailbox, providers are encouraged to use resources within their individual organizations as well as resources available on online. Visit www.medica.com to refer to Coding Tools and Forms (http://provider.medica.com/C12/CodingToolsForms/default.aspx). After exhausting these resources, providers may contact the Provider Service Center regarding a coding inquiry, and when doing so should be prepared to provide specific claim details including audit number, date(s) of service, and procedure code. |
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| Date: 7/17/2007 |
| Description: CPT codes 92340-92342 and 92370-92371 incorrectly denying with reason code 664 |
| Alert: Medica has identified a system error for CMS-1500 claims when CPT codes 92340-92342 and 92370-92371 were submitted and denied with reason code 664 ("Eyeglasses/ contacts are not covered"). This applies to dates of processing of 4/18/07 to 7/2/07. This error only impacted claims submitted on behalf of Medica’s Minnesota Health Care Programs members. Medica has corrected the system and has identified all impacted claims. Providers should notice the adjustment within 60 days. |
| Action: Providers do not need to submit adjustment requests. All affected claims will be reprocessed. |
| Products Impacted: Medica Choice CareSM and Medica MinnesotaCare (not including MinnesotaCare Limited) -- group numbers 59119, 59619, 59117, 59617, 59118, 59618, 59517, 59717, 59518, 59718, 59523, 59723, 59522, 59722, 59524, 59724. |
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| Date: 6/28/2007 |
| Description: Medica COB Policy to be Consistent for All Claims |
| Alert: Medica has implemented a systems change to be consistent in investigating coordination of benefits (COB) on an initial claim for each new member, regardless of the claims administration system used. As a result, COB information will be pursued with the first claim per member for all Medica claims; there will be no threshold with a $400 claim level required prior to pursuing COB for any claims processed on Medica's new claims administration system. |
| Action: No action required. |
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| Date: 6/13/2007 |
| Description: Medica.com Eligibility Transaction Has Errors When the Primary Care Clinic is Loaded with an NPI number |
Alert: Medica.com eligibility transactions can not be executed when an NPI number is used for the primary care clinic. Medica is working to correct this issue and plans to have this error corrected mid-August. This error only affects transactions on www.medica.com. This does not affect other electronic vendors such as Emdeon or ClaimLynx.
Update: Medica regrets that the above error has not yet been resolved. Medica remains committed to fixing the error and hopes that the error will be fixed soon. Until the fix is implemented, the transaction will display limited data, only verifying if a member is eligible or not (no PCC or copays will display). |
| Action: If you receive an error when checking eligibility on www.medica.com, please contact the Provider Service Center at: 1-800-458-5512. |
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| Date: 6/12/2007 |
| Description: Medica's new process for set-up of NPI numbers |
Alert: Medica is transitioning its ongoing maintenance of systems set-up for all national provider identifier (NPI) numbers -- both facility and individual practitioner NPIs. This change is effective immediately. To submit NPIs to Medica, please use the standard process followed for all demographic change requests. Click on the following link to see how to notify Medica of such changes: http://provider.medica.com/C18/ProviderDemo/default.aspx. Providers may use either the Minnesota HIPAA Collaborative NPI submission form or the Minnesota Uniform Practitioner Change Form to send Medica NPIs. These forms may be returned to Medica by e-mail at demographicchangerequests@medica.com, by fax to 952-992-2249, or by U.S. mail to this postal address:
Medica Provider Demographics
Route CP412
PO Box 9310
Minneapolis, MN 55440-9310 If you haven't already submitted your NPI to Medica, it may take 2-3 weeks to set up the NPI numbers in the Medica system before you can begin using the NPI on claims. Medica confirms receipt of NPI submissions. Then, prior to submission of an NPI on claims, providers can verify the existence of an NPI in Medica's system. To do this, use the Provider Search function (under Electronic Transactions, at http://provider.medica.com/C6/ElectronicTransactions/default.aspx) -- which indicates NPIs associated with each provider. Otherwise, providers may call the Provider Service Center at 1-800-458-5512. Referring providers can also use the search function to find NPIs for other providers (specialists, hospitals, etc.).
As a reminder, until further notice, you may use your NPI number and/or your Medica ID number to submit claims to Medica. |
| Action: If you have not already done so, please submit your NPI numbers using the above e-mail, fax or mailing address. If you have questions, an NPI Q&A is available at http://provider.medica.com/C13/ClaimsToolsForms/default.aspx, or you may call the Provider Service Center. |
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| Date: 5/25/2007 |
| Description: Medica's turnaround time for set-up of NPI numbers |
| Alert: Due to a last-minute rush of national provider identifier (NPI) numbers submitted to Medica, Medica may require 2-3 weeks to set up the NPI numbers in its system before providers can begin using the NPI on claims. If you submitted your NPI in an ENUF file, the turnaround time is the quickest, at one week, after which you should be able to submit claims using your NPI. As a reminder, until further notice, you may continue to use either your NPI number or your Medica ID number to submit claims to Medica. |
| Action: If you have not already done so, please submit your NPI numbers, including a unique identifier for each practitioner (SSN, UPIN, Medica billing number), using an ENUF file to David Andersen at david.andersen@medica.com. If unable to submit using an ENUF file or an electronic Excel list, fax NPIs to Medica at 952-992-3270 (note that this is a corrected fax number). The fax machine has been in constant use, so if you fax and receive a busy signal, you may need to try submitting your information more than once. |
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| Date: 5/24/2007 |
| Description: UHC contract changes may affect EDI vendors |
| Alert: With its recent acquisition of Electronic Network Systems, Inc. (ENS) and Claredi, UnitedHealthcare aims to streamline EDI processes. As a result, UHC is renegotiating its contracts with fee-based vendors/clearinghouses that providers may be relying on to submit claims. These contract changes should not affect how providers submit claims. However, the submission of EDI claims is outside Medica's control since that is a function of these vendors. Clearinghouses should be able to continue sending and receiving all of the transactions that they do now, with no impacts to providers. |
| Action: If you have questions or concerns regarding the service provided by your clearinghouse, you should contact your vendor directly. Medica offers a guide outlining the services provided by some of the most prominent vendors/clearinghouses. To view this guide, click here. Or on www.medica.com, visit Provider Resources, then General Tools and Forms, under Electronic Commerce. |
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| Date: 5/18/2007 |
| Description: Effective immediately, providers may begin submitting claims using NPI only. |
| Alert: Medica is ready to accept claims submitted with a national provider identifier (NPI) number only, as the Medica provider ID is no longer required. This applies for all paper and electronic claim formats (CMS-1500, UB-04, and 837). Please note that, until further notice, you may continue to use either your NPI number or your Medica ID number to submit claims to Medica. |
| Action: If you have not already done so, please send a list of your NPI numbers to David Andersen at david.andersen@medica.com or by fax to (952) 992-2764. For additional information on how to complete the UB-04 or the new CMS-1500 claim forms, please click on http://provider.medica.com/C13/ClaimsToolsForms/default.aspx or visit www.medica.com, in the Provider Resources section under Tools and Forms, then Claims Tools and Forms. Finally, more NPI-related details were included in the June 2007 Medica Connections, available at this Web page: http://provider.medica.com/Connections/default.aspx. |
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| Date: 5/14/2007 |
| Description: Online Co-pay and Co-Insurance Verification for Groups on New Business Platform Inaccurately Showing $0.00 |
| Alert: Medica has identified an issue with co-pay and co-insurance inaccurately showing $0.00 for groups on new business platform. When checking online eligibility for these groups, the co-pay line will read $0.00 and the co-insurance line will appear blank. This issue affects medica.com transactions as well as transactions for all other claims vendors. |
| Action: Medica is working to resolve this issue and will provide notification when this issue has been corrected. Please continue to check member ID cards and use the Provider Service Center to verify co-pay and co-insurance amounts for these members. Providers can contact the Provider Service Center at: 1-800-458-5512. |
| Products Impacted: All groups on new business platform: Allianz (group # 710287), Ameriprise (group # 708550), General Dynamics (group # 217725), Nestle (group # 333000), Pepsi Co. (group # 191690), Pinnacle Airline (group # 710705), Unisys (group # 701182), Best Buy (group # 703352), Medica (group # 710668), Frandsen (group # 710724), Target (group # 185002), UHC (group # 168504), and Individual Business. |
| Date: 3/30/2007 |
| Description: Medica's High-Tech Imaging Program - correction on fax number for appeals |
| Alert: In previous communications, the fax number to use for submitting High-Tech Imaging Program administrative appeals was incorrectly published. The correct fax number to use is 952-992-3270. There is also a process in place at Medica to forward appeals that are submitted to the incorrect fax number. |
Action: As a reminder, performing providers can submit administrative appeal requests to Medica via mail, fax or e-mail:
Medica
Attn: CP345 Radiology Appeals
PO Box 9310
Minneapolis, MN 55440-9310
Fax: 952-992-3270
provider.analysts@medica.com Both the High-Tech Imaging Program Administrative Appeal Form and Appeal Policy have been updated and re-posted online under High-Tech Imaging on the Claims Tools and Forms web page at http://provider.medica.com/C13/ClaimsToolsForms/default.aspx.
If you have questions or need further information about Medica's High-Tech Imaging Program:
• See more details about the program at http://provider.medica.com/C13/ClaimsToolsForms/default.aspx
• Call Medica's Provider Service Center at 1-800-458-5512 |
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| Date: 3/09/2007 |
| Description: Medica's High-Tech Imaging Program - clarification that consultation requirement is not for performing providers |
| Alert: Just as a reminder, Medica’s High-Tech Imaging Program requirement for making consultation requests applies to ordering providers only. The consultation process is intended to provide real-time decision support for physicians considering ordering high-tech imaging studies. This process does not apply for performing provider sites, so the only reason performing providers may need to contact HealthHelp is to verify that an ordering provider completed a consultation and a reference number was issued prior to performing the service. |
Action: As of March 1, ordering providers can use Medica's secure web page for online consultation requests. This is available on "Provider Resources" under Electronic Transactions. After logging in and selecting “Prior Authorization, Notification, and High-Tech Imaging Request,” click on the button for “High-Tech Imaging” on the next screen.
If you have questions or need further information about Medica's High-Tech Imaging Program:
- See more details about the program at Claims Tools and Forms
- Call Medica's Provider Service Center at 1-800-458-5512.
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| Date: 3/09/2007 |
| Description: Medica accepts UB-04 as of March 1, 2007 |
| Alert: Medica is ready to receive the new UB-04 as of March 1, 2007. For additional information on the UB-04 history and requirements, providers should review the Medica-specific guide to completing the UB-04 and well as the UB-04 FAQ posted on www.medica.com under the “Provider Resources” section, then “Tools and Forms”, then “Claims Tools and Forms” in the “Claim Forms” subsection (or at http://provider.medica.com/C13/ClaimsToolsForms/default.aspx). Medica will also be addressing the UB-04 changes in the upcoming Life of a Claim training sessions. |
| Action: Please check www.medica.com and future editions of Connections for updates. |
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| Date: 3/08/2007 |
| Description: A portion of the new 2007 CPT codes were not added to Medica’s service code list until 2/12/2007. |
| Alert: A portion of the new 2007 CPT codes were not added to Medica’s service code list until 2/12/2007. As a result, claims edited to the incorrect service code causing incorrect co-pays to be taken and limited services not being posted. The system was updated on 2/12/2007. This impacts all claims processed between 1/1/2007 and 2/12/2007. |
| Action: No provider action required. Medica has identified all impacted claims and adjustments will be done accordingly. |
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| Date: 2/23/2007 |
| Description: Medica's High-Tech Imaging Program - program developments and additional tools |
Alert/Action: Here are several clarifications and program developments as part of Medica's consultation process for outpatient high-tech diagnostic imaging studies:
- As of March 1, providers will be able to use Medica's secure web page for online consultation requests. This is available on "Provider Resources" under "Electronic Transactions" (at https://provider.medica.com/C6/ElectronicTransactions/default.aspx)
- A step-by-step guide will be available here to assist ordering providers with completing online consultation requests as of March 1.
- Note: Ordering providers will need to include the performing provider Medica ID number with each online consultation request. A list of performing provider ID numbers is available on the secure web page as well as under "Tools and Forms," then "Claims Tools and Forms" in the "High-Tech Imaging" subsection (http://provider.medica.com/C13/ClaimsToolsForms/default.aspx)
- Providers will need to have pre-registered for Medica's electronic transactions to be able to log in and use the secure web page. If you have not previously registered, please visit the secure web page indicated above or contact the Provider Service Center at the phone number below.
- With each consultation request, ordering providers can choose to include the fax number for the performing provider location. This will ensure that the reference number associated with a particular case is received by the performing provider. If the fax number for the performing facility is not included, the performing facility will not receive a fax. Best practice shows it is helpful for the ordering provider to also include the refererence number on the order to the performing facility. This confirms that a consultation was completed and enables appropriate payment for scans.
- If a scan needs to be scheduled the day of the consultation request, providers should call HealthHelp toll-free at 1-800-954-3040. Providers will also be able to make such expedited requests online as of March 1.
- Performing providers can verify the existence of a reference number for a requested scan by calling HealthHelp. Providers may also call the ordering provider's office to verify if a reference number has been issued.
- By March 1, a new list of product and provider exceptions to the High-Tech Imaging Program consultation requirement will be available under "Tools and Forms," then "Claims Tools and Forms" in the "High-Tech Imaging" subsection (http://provider.medica.com/C13/ClaimsToolsForms/default.aspx). This exception list will include two components:
- This reference tool will list Medica's products with employer group numbers to assist both ordering and performing providers with understanding which patients are not included with this phase of the High-Tech Imaging Program -- These are members for whom the consultation process is not currently required.
- Also listed on this reference tool are alternative provider programs -- Medica has approved certain provider entities that are using evidence-based criteria to have an alternative method to point-of service consultation. Ordering providers using these alternative programs, rather than Medica's consultation program, will not be required toobtain a reference number from HealthHelp. As a result, performing providers can perform scans ordered by providers of these organizations without a reference number and corresponding claims will not be denied.
- Starting next month, Medica's Provider College will be hosting weekly open forums by webinar to answer questions and address issues related to the High-Tech Imaging Program. You should soon see an invite to attend, which will include information on registering. If you have questions about these forums, send an e-mail to: providercollege@medica.com
If you have questions or need further information about Medica's High-Tech Imaging Program:
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| Action: [enter Action Text here] |
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| Date: 2/22/2007 |
| Description: High-Tech Imaging Open Forums are being offered every Friday through the month of March to address provider questions or concerns around the new high-tech imaging program |
| Alert: Medica’s Provider College has invited you to join a meeting on the Web, using WebEx. These sessions will be held every Friday in March from 9-10 am. Each session will include helpful process tips and discuss any program developments, but the majority of the hour will be spent answering any questions you have about this program. Dedicated high-tech imaging program experts will be available to take your feedback and address any questions you may have. |
Action:
- You can participate in the session by calling: 866-469-3239.
- Web viewing not required to actively participate in the session.
- Please click the following link to see more information, or to join the meeting: https://medica.webex.com/medica/j.php?ED=92563437&UID=54591342. NEW USER? Prepare your computer in advance of the meeting by clicking New User on the navigation bar.
- For questions regarding a particular member, please continue to contact the Provider Service Center at: 1-800-458-5512.
- Meeting number: 801 068 637
- Meeting password: HealthHelp
- Meetings being held every Friday in March starting March 2, 2007 through March 30, 2007
- Time: 9:00 am – 10:00 am
To add this meeting to your calendar program (for example, Microsoft Outlook or Lotus Notes), do the following:
- For all calendar programs (except Lotus Notes), click the following link, or copy the link and paste it into your Web browser:
https://medica.webex.com/medica/j.php?ED=92563437&UID=54591342&ICS=MI
- For Lotus Notes, follow these steps:
- Right-click the attached iCalendar format (*.ics) file, and then choose View.
- Click Import All. A new broadcast email message is added to your Inbox.
- Open the new message.
- Click Respond button. A menu appears.
- Click Accept.
The host requests that you check for compatibility of rich media players for Universal Communications Format (UCF) before you join the session. UCF allows you to view multimedia during the session. To check now, click the following link: https://medica.webex.com/medica/systemdiagnosis.php |
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| Date: 1/16/2007 |
| Description: Follow-up on notification with consultation requirement for ordering providers as part of Medica's new High-Tech Imaging Program |
Alert: As of January 1, Medica began rolling out a notification with consultation process for outpatient high-tech diagnostic imaging studies. Physician offices may participate in up to 3 levels of review to complete this process:
- For Level 1, the notification with consultation is with a client services representative, and the provider office should have a staff member with a clinical background consult with HealthHelp. 80% of the time, the process can be completed at Level 1, but the person making the call needs to be able to answer clinically scripted questions and have access to the patient's chart.
- If rules can't be met at Level 1 based on the information received, the call is sent on for a nurse-to-nurse review at Level 2. The additional review is only to answer additional questions and does not mean that your case does not meet rules. The Level 2 review may necessitate a callback from HealthHelp to your office for the additional information, which should take place within 4 hours of your call.
- If necessary after a nurse review at Level 2, the case may be referred to Level 3 for a physician-to-radiologist review.
Reminder: Escalated reviews will never mean they are "denied." The process is consultative only, and a final decision on patient care continues to rest with the ordering physician. |
Action: To help cases meet rules at Level 1 so they don't need to move to Level 2, it would be helpful for ordering provider offices to have patient chart, notes or history available for initial consultations with HealthHelp. If submitting a fax form for a consultation request, complete the form as fully as possible. The form should contain as much information as necessary to describe why the requested procedure is being ordered. The required information only needs to be pertinent to the test being ordered. Doing this will help to facilitate quicker turnaround times for providers. Best practices for making requests have included:
- Having a clinical staff member make calls.
- Photocopying the fax form with unchanging provider information on it, so you don't have to repeatedly fill out the same information.
- Customizing the fax form to include clinical information that your office typically needs when ordering high-tech services.
- Highlighting Medica members on charge tickets so they're flagged as needing the outside notification (and reference number after completing the consultation).
If you have questions or need further information:
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