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Provider Alert Archive


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.
  1. 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

  2. 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
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.

  1. 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
  2. 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.
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.

  1. 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.
  2. 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.
  3. Ultraviolet phototherapy as a treatment for active acne vulgaris is considered investigative and therefore is not covered.
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: 03/16/2009
Description: Medica Updates its Provider Administrative Manual
Alert: Effective March 16, 2009, the Medica Provider Administrative Manual has a new look and format. All the content from the old version has been reorganized into a more streamlined, user-friendly version consisting of HTML web pages instead of pdf documents. A key to help providers navigate their way through this new format is posted on the administrative manual's home page. Instead of 21 chapters, the manual now has a modified menu of 11 primary topics.
Action: No action is required.View Medica Provider Administrative Manual.
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: 01/09/2009
Description: Enhanced Eligibility Inquiry Transactions Now Available Online
Alert: Medica has implemented enhancements to its electronic eligibility request (HIPAA transaction 270) and eligibility response (271) functions, consistent with Minnesota state legislation and guidance from the Minnesota Administrative Uniformity Committee (AUC). For details on the eligibility request and response enhancements, see the December 2008 edition of Medica Connections, page 15.
Action: Providers are now able to begin using this new and improved eligibility functionality through the secure Electronic Transactions web page.
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.

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.

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.

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.
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).

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.

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.

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.
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.

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.
    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.

    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.
    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.

    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.

    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.

    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.

    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.

    Date: 5/19/2008
    Description: Medica’s PRA has been updated to include additional information
    Alert: Medica's Provider Remittance Advice (PRA) has been updated to include additional information. Changes were implemented May 17, 2008.
    Action: The following reference tools explain formatting of the new PRA.

  • Medica’s New Provider Remittance Advice
  • Provider Remittance Advice Explanation of Fields

    • 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:
    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.
    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.
    Date: 12/07/2007
    Description: Limited Availability of Medica Electronic Transactions This Weekend.
    Alert: From midnight Friday, December 7, to midnight Sunday, December 9, there will be limited availability of Electronic Transactions (e.g., copay info, eligibility) on www.medica.com. This is due to scheduled maintenance. We apologize for any inconvenience.
    Action: No action required.
    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.
    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.

    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.
    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).
    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.

    Action: Should this change require an alteration to your reimbursement, your Contract Manager will contact you.
    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.
    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.
    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.
    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.
    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.
    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.
    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.
    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.
    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.
    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
    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.
    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.
    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.
    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:
    1. 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.
    2. 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.
    3. 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.
    4. 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.
    5. 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.
    6. 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:
    Action: [enter Action Text here]
    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:
      1. Right-click the attached iCalendar format (*.ics) file, and then choose View.
      2. Click Import All. A new broadcast email message is added to your Inbox.
      3. Open the new message.
      4. Click Respond button. A menu appears.
      5. 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
    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:
    1. 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.
    2. 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.
    3. 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:
    1. Having a clinical staff member make calls.
    2. Photocopying the fax form with unchanging provider information on it, so you don't have to repeatedly fill out the same information.
    3. Customizing the fax form to include clinical information that your office typically needs when ordering high-tech services.
    4. 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:
    Date: 12/19/2006
    Description: Provider Service Center to phase out local number on Friday, December 29th
    Alert: Medica’s Provider Service Center currently offers the provider network two incoming phone options: local number 952-992-2232 and toll-free number 800-458-5512. To allow for heightened flexibility and capacity, the Provider Service Center will begin to phase out the local number on Friday, December 29th and will only use the toll-free number. Medica encourages providers to begin using the Provider Service Center’s toll-free number immediately. Medica is in the process of updating all provider materials to reflect only the toll-free number.
    Date: 11/22/2006
    Description: Access to existing provider portal transactions changing November 29, 2006
    Alert: Medica's new, more secure portal for online transactions, will be available on November 29, 2006, at which point providers will no longer have access to existing online transactions using their current username and password. As of next Wednesday, November 29th, all users will need to be registered in the new system and use their new username and password to have access to electronic transactions. Please register in advance of that deadline if you have not done so.
    Action: Each Organization’s Primary Administrator should register using the following steps:
    1. If possible, temporarily disable any pop-up blocker you may have running on your system
    2. Go to www.medica.com, hover your mouse over the Provider Resources tab and select Electronic Transactions
    3. Select the blue “Registration Account Management” link at the top of the page
    4. Scroll to the bottom of the page and select the “Register Provider Organization and Primary Admin” link
    5. When you click on "Submit," a window will pop up with a form that displays your information
    6. Print this form, review and sign it, and mail or fax it to Medica
    7. Once Medica receives your form, you will receive two e-mails: the first is acknowledgment of receiving the form, and the second will be a secure e-mail containing the link to complete the registration by setting up your username and password
    To assist you, a Registration User Guide has been posted in the Provider Resources section on www.medica.com under Administrative Manuals.

    If you have a question concerning registration, please contact us at portalregistration@medica.com or Contact Medica’s Provider Service Center at: 1-800-458-5512.
    Date: 11/09/2006
    Description: New mailing address for Medica claims
    Alert: Effective 11/1/2006 Medica changed the mailing address for paper claims from San Antonio, Texas, to the following:
    Medica
    PO Box 30990
    Salt Lake City, UT 84130
    Action: Medica encourages all providers to promptly update their systems to help ensure timely claims payment. The percentage of claims still submitted to the old address is very high.
    Date: 10/31/2006
    Description: Claims Address Changed
    Alert: Medica has changed the mailing address for paper claims from San Antonio, Texas, to Salt Lake City, Utah. Providers should be submitting claims to the following address:
    Medica
    PO Box 30990
    Salt Lake City, UT 84130
    Action: Providers should be sending paper claims and certified mail to the Salt Lake City, Utah address.
    Products Impacted: The new single address applies to all Medica lines of business (including Medica DUAL Solution® and Medica Advantage SolutionSM) except SelectCareSM, LaborCare® and United Behavioral Health (UBH).
    Date: 9/27/2006
    Description: Modifier QW Denials for Laboratory Codes – Only Affects Groups #168504 and #185002.
    Alert: Medica has identified a claims system error that is causing an incorrect denial on laboratory codes submitted with modifier QW (CLIA waived test). The denial reason is FE ("Incorrect Modifier"). Medica has requested a correction to the system with anticipated completion in October 2006. Following the correction to the system, Medica will run a report to identify all affected claims for reprocessing. Codes for laboratory services submitted without the QW modifier will process according to the provider contract.
    Action: No action is required from providers at this time.
    Date: 9/20/2006
    Description: Incorrect maternity benefit assignment to claims for Group #185002.
    Alert: Medica has identified a claims system error, which assigned an incorrect benefit to claims submitted for maternity services beginning with April 1, 2006, dates of service. A correction to the system was completed on August 22, 2006. Medica has identified all claims impacted by this error and is in the process of adjusting claims. The target completion date for adjustments is September 30, 2006.
    Action: No action is required from providers at this time.
    Date: 9/12/2006
    Description: Physician and Facility Claims Incorrectly Denied Reason Code 068 (Not a covered service).
    Alert: Medica has identified a claims system set-up error which caused both physician and facility claims to be denied with reason code 068 (Not a covered service). This only has an impact on claims with checkwrite dates of 9/6/2006-9/8/2006. Medica is in the process of identifying all claims that were inappropriately denied and adjustments will be done accordingly. Medica will continue to update providers as more information becomes available.
    Action: No action is required from providers at this time.
    Updated: 10/26/2006
    Date:     9/08/2006
    Description: System error causing inappropriate 251 denials for 3 vision codes submitted on CMS-1500.
    Alert: Medica has identified a system error for CMS-1500 claims when CPT codes 92081, 92083 and 92083 (visual fields) were submitted and denied with reason code 251 (Doesn’t meet NCD/LCD policy criteria). This applies to dates of processing of 6/19/06-9/07/06. This error should only have affected claims for services performed by MN and WI optometric and ophthalmological providers. 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.
    Update: All affected claims have been identified and reprocessed.
    Updated: 10/26/2006
    Date:     9/08/2006
    Description: System error causing inappropriate 251 denials for 2 diabetes-related HCPCS codes submitted on CMS-1500.
    Alert: Medica has identified a system error for CMS-1500 claims when HCPCS codes A5512 and A5513 (for diabetics only, multiple density inserts) were submitted and denied with reason code 251 (Doesn’t meet NCD/LCD policy criteria). This applies to dates of processing of 6/14/06-9/07/06. Criteria from two different DME policies was mistakenly combined, resulting in the incorrect denials. This error should only have affected claims for services performed by MN and WI suppliers of diabetic shoe accessories. 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.
    Update: All affected claims have been identified and reprocessed.
    Date: 8/18/2006
    Description: System error causing inappropriate 251 denials for CPT codes 97110, 97112, 97116, 97530, 97532, 97533, 97535 and 97537 submitted on a CMS-1500 or UB-92.
    Alert: Medica has identified a system error for CMS-1500 and UB-92 claims when CPT codes 97110, 97112, 97116, 97530, 97532, 97533, 97535 and 97537 were submitted and denied reason 251 (doesn’t meet NCD/LCD policy criteria) for dates of processing 6/5/06 – 8/19/06. Medica has corrected the system error and will run a report to identify all affected claims for reprocessing. Not all denials were inappropriate. Providers can access the Wisconsin Physicians Service (WPS) website for the most current policy criteria for Physical Medicine and Rehabilitation Procedures and Modalities.
    Action: No action needed at this time. Providers do not need to submit adjustment requests.
    Date: 8/11/2006
    Description: Coding Questions mailbox, expected turnaround time
    Alert: Due to staffing changes to support other Medica initiatives, Medica will temporarily have fewer resources dedicated to the "Coding Questions" email box and faxes which may result in a delayed response.  At this time we request providers not submit duplicate questions to the “Coding Questions” email box. However, providers who require immediate assistance may flag their question as such.

    NOTE: You may find additional resources available by utilizing the search functionality on medica.com in either “Connections” or the Reimbursement/Claims Policies.
    Date: 8/11/2006
    Description: Delay in loading electronic claims
    Alert: Medica is currently experiencing a 5-day turnaround time in the loading of electronic claims into its claims processing system. This is only affecting commercial claims. The claims are being loaded and processed in the order they are received. An update will be available as soon as the issue is resolved.
    Action: When checking claim status for electronic claims, please keep in mind there is a delay in load time.
    Date: 8/08/2006
    Description: Provider Service Center to Temporarily Change Service Hours
    Alert: Medica Provider Service Center will temporarily be changing its hours, closing from noon-1 PM Monday through Friday. This will be effective beginning Wednesday, August 9. The new hours will be:
    • Monday-Thursday: 8:30 AM to noon and 1-5 PM
    • Friday: 9 AM to noon and 1-5 PM
    This change is intended to reduce wait times by providing a full staff during all hours of operation. These temporary hours will be in place until further notice. We apologize for the inconvenience this may cause you or your office. Self-service options will continue to be available during this time via the automated phone system or www.medica.com. We will communicate future updates or changes to hours as necessary. We appreciate your patience.
    Date: 8/01/2006
    Description: Medica Claim/Reimbursement Policies now Available on medica.com
    Alert: Medica’s Claim/Reimbursement Policies have been posted online to assist providers with coding and submitting claims to Medica for covered health services.
    Action: Visit www.medica.com, under “Provider Resources,” “Tools and Forms,” then “Reimbursement/Claim Policies” (available directly at http://provider.medica.com/C14/ClaimPolicies/default.aspx). If you have questions on any of the listed policies, please send an e-mail to coding.questions@medica.com.
    Date: 7/28/2006
    Description: FDA Approves New Vaccine for Prevention of Cervical Cancer
    Alert: The Food and Drug Administration approved Gardasil, on June 8, 2006, the first vaccine developed to prevent cervical cancer, precancerous genital lesions and genital warts due to human papillomavirus (HPV) types 6, 11, 16 and 18. The vaccine is approved for use in females 9-26 years of age.
    Effective June 8, 2006, CPT code 90649 Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use will be eligible for reimbursement for females ages 9-26.
    Action: No action is required from providers.
    Date: 7/28/2006
    Description: System error causing inappropriate 251 denials for CPT lab code 80061 submitted on a CMS-1500 or UB-92.
    Alert: Medica has identified a system error for CMS-1500 and UB-92 claims where CPT lab code 80061 (Lipids panel) was submitted and denied reason 251 (doesn’t meet NCD/LCD policy criteria) for dates of processing 6/27/06 and forward. 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.
    Date: 7/28/2006
    Description: National Coverage Decisions (NCD) and Local Coverage Decisions (LCD)
    Alert: Medica is currently up to date with the National Coverage Decisions (NCD) and Local Coverage Decisions (LCD) for Medica Prime Solution, group numbers 70200-70299 and 70500-70599. Medica will have the newly created or revised NCDs and LCDs reviewed and implemented in our claims system within 30 days of receipt of notification from the Centers of Medicare and Medicaid Services (CMS) or the state contractors (please see below). Please note that adjustments may be done if a policy is implemented retroactively.
    Action: If you would like to review the most current policies, please select the appropriate link below.

    Wisconsin Physician Services (Minnesota & Wisconsin) - WPS Medicare Part B
    TriCenturion (Minnesota & Wisconsin DME) - TriCenturion (DME)
    Noridian Administrative Services, LLC (North Dakota & South Dakota) - Noridian Administrative Services, LLC Part B
    Electronic Data Systems Corp (North Dakota & South Dakota DME) - Electronic Data Systems Corp (DME)
    CMS National Coverage Decision Database - Centers for Medicare & Medicaid Services (NCD Database)
    Product Impacted: Medica Prime Solution, group numbers 70200-70299 and 70500-70599
    Updated: 10/20/2006
    Date:     7/20/2006
    Description: FDA Approves New Vaccine to Reduce Risk of Shingles
    Alert: On May 25, 2006, the Food and Drug Administration (FDA) approved Zostavax, a new vaccine for the prevention of herpes zoster (shingles) in people 60 years of age and older, who are not immunocompromised.

    Zostavax, an attenuated live virus vaccine, is given as a single injection under the skin, preferably in the upper arm.

    Effective May 25, 2006, CPT code 90736 Zoster (shingles) vaccine, live, for subcutaneous injection will be eligible for reimbursement for individuals ages 60 and above.
    Action: No action is required from providers.
    Update: Medicare Part B and replacement policies do not pay for code 90736, the associated administration fee and other services (office visit) which are primarily for the purpose of administering a non-covered injection. A patient’s Medicare Part D plan may provide reimbursement for the vaccine, but this would be subject to each individual coverage document.
    CPT 90736 is assigned an “E” status indicator in the National Physician Fee Schedule: Excluded from Physician Fee Schedule by regulation. These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation.
    Date: 6/19/2006
    Description: Aetna has one Provider Appeal Address
    Alert: In an effort to simplify the process for resolving provider claim and utilization review appeals, Aetna has consolidated the mailing addresses. Effective immediately, please send all Aetna appeals to the following post office box:
    Aetna
    Provider Resolution Team
    P.O. Box 14020
    Lexington, KY 40512
    For more information on the provider appeal process, please visit www.aetna.com, select “Doctors & Hospitals”, click on “Services and Tools”, then “Medical Resources.”
    Products Impacted: SelectCare
    Date: 6/19/2006
    Description: Some providers not correctly linked to care groups for Elect / Essential Products
    Alert: Medica has identified an error where claims are paying the incorrect benefit level when services are received from a specialist within the member’s primary care clinic or from a doctor care grouped with the primary care clinic. The error affects dates of service 1/1/06 - 6/8/06.

    Medica is in the process of identifying all claims impacted. Appropriate adjustments will be made within 60 days.
    Action: No action required from providers at this time.
    Products Impacted: Medica Elect and Medica Essential
    Updated: 8/01/2006
    Date:     6/09/2006
    Description: 251 claim denials being adjusted for Medicare members (Adjustments Completed)
    Alert: A system error was recently identified regarding claims for Medicare members. As a result of this error, claims entered on 6/8/2006 for members enrolled on groups 70200-70220 and 70500-70599 may have been inappropriately denied with a 251 denial code (Doesn’t Meet Medicare NCD/LCD Criteria). The system has been corrected and a report is being pulled and worked in order to adjust the claims affected by this error.
    Action: If you recognize claims that were affected by this error, it is NOT necessary to send an adjustment request. As noted above, a report is being pulled and all claims will be adjusted appropriately.
    Products Impacted: Medicare groups 70200-70220 and 70500-70599
    Date: 6/01/2006
    Description: Medica to Implement 'Centers of Excellence for Bariatric Care' Program, effective July 1, 2006
    Alert: Effective July 1, 2006, Medica will launch its new Centers of Excellence program for bariatric care, for which designated providers have completed a rigorous application process through the American Society of Bariatric Surgeons. The full Centers of Excellence list is available on www.medica.com in the "Clinical Programs" section, under "Centers of Excellence" (or by clicking here). After July 1, benefits for Medica members will vary depending on their coverage document and should be verified prior to receiving services.
    Action: For a full description of the program, see page 1 of the May 2006 Medica Connections, available on www.medica.com in the "Newsletters" section, under "Connections" (or by clicking here). Please note that bariatric surgery will continue to require prior authorization.
    Date: 5/30/2006
    Description: The Medica Authorization for Termination of Care form has been updated
    Alert: You are able to locate the new form online at www.medica.com, under Provider Resources, then Reporting Obligations (or directly at: http://provider.medica.com/C19/ReportingObligations/default.aspx). This form is also available via Medica’s literature request line at: 952.992.2355.
    Action: 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. To do so, providers should use the Medica Authorization for Termination of Care Form. Providers may reference Medica’s Provider Administrative Manual, Chapter 14, Section B, subsection 4 (available at http://provider.medica.com/C6/ProviderManualAdmin/default.aspx) for more information on the provider refusal-of-care process.
    Date: 5/30/2006
    Description: Medica to update its drug formulary and add selective step therapy, effective July 1, 2006
    Alert: Effective July 1, 2006, several medications, including particular branded supplements and prenatal vitamins, will be removed from Medica's drug formulary. Step therapy will also be required for the following therapeutic classes: Angiotensin II Receptor Blockers (ARBs), Proton Pump Inhibitors (PPIs), and antidepressants.
    Action: The full Medica Drug Formulary is available online on the "Pharmacy" page, under the "Medica's Drug Formulary" column heading, or by clicking here.
    Date: 5/01/2006
    Description: Medica Removes Prior Authorization for Thoracic Sympathectomy for Hyperhidrosis
    Alert: Effective June 1, 2006, prior authorization will no longer be required for thoracic sympathectomy for hyperhydrosis. Medica will continue to monitor utilization of the procedure and may conduct claim audits. Thoracic sympathectomy for the treatment of palmar hyperhidrosis is used for patients with intractable, disabling, primary hyperhidrosis who have failed to respond to medical management.
    Note: Thoracic sympathectomy for the treatment of axillary, plantar, and other forms of hyperhidrosis is investigative and therefore not eligible for coverage.

    As of June 1, 2006, the complete text of the revised utilization management (UM) policy that applies to this procedure (“Thoracic Sympathectomy for Hyperhidrosis”) will be available on www.medica.com in the “Provider Resources” section under “Medical Policies”.
    Date: 5/01/2006
    Description: Medica Removes Prior Authorization for Home Care Services for Medica HMO Conversion Plan Members, Except for Home Health Aide Services
    Alert: Effective June 1, 2006, prior authorization will no longer be required for Home Care Services for Medica HMO Conversion Plan members, except for home health aide services, which will continue to require prior authorization for all Medica products.

    As of June 1, 2006, the complete text of the revised utilization management (UM) policy that applies to this procedure (“Adult Home Health Care”) will be available on www.medica.com in the “Provider Resources” section under “Medical Policies”.
    Products Impacted: HMO Conversion plan: Group Numbers: 50000, 50013, 50014.
    Date: 3/14/2006
    Description: FDA Approves New Rotavirus Vaccine
    Alert: On February 3, 2006 the Food and Drug Administration (FDA) announced the approval of RotaTeq™, a live, oral, vaccine for use in preventing rotavirus gastroenteritis in infants. RotaTeq™ is a liquid vaccine that is given by mouth in three doses, between the ages of 6 and 32 weeks.

    Effective February 3, 2006, CPT code 90680 (Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use) will be eligible for reimbursement for members up to one year of age.
    Action: No action is required from providers.
    Date: 3/06/2006
    Description: System set up error causing codes G0378 and G0379 to incorrectly deny reason code 479 on hospital claims. (COMPLETED)
    Alert: Medica has identified a system setup error which caused codes G0378 and G0379 to incorrectly deny reason code 479 (Resubmit under other code for processing) on hospital claims.

    Medica is in the process of identifying all claims that were inappropriately denied and adjustments will be done accordingly.
    Action: No action is required from providers.
    Impact: This impacts claims processed between 1-1-06 and 2-27-06.
    Updated: 2/08/2006
    Date:     1/25/2006
    Description: System set-up error causing claims to deny reason codes 031, 068, 022 and 633.
    Alert: Medica has identified a system set-up error which caused claims, both physician and facility, to deny for the following reason codes:
    • 031: Your plan does not cover this expense
    • 068: Not a covered service
    • 022: No eligible charge don’t bill patient
    • 633: DME not covered
    Medica is in the process of identifying all claims that were inappropriately denied and adjustments will be done accordingly. Medica will continue to update providers as more information becomes available.
    Action: No action is required from providers at this time.
    Impact: This impacts claims with a check-write date of January 25, 2006, January 29, 2006 and January 31, 2006.
    Date: 1/23/2006
    Description: On-line Claim Adjustment Request Form Now Available
    Alert: A new On-Line Claim Adjustment Request form is now available on medica.com. The On-Line Claim Adjustment Request form is used to indicate if information on the claim is missing or invalid, or the provider is challenging reimbursement on the claim. Please note that once the on-line form is submitted it is forwarded electronically to Medica’s claim processing site and follows the current Claim Adjustment Request processes. It may take up to 48 business hours to be entered into the claims payment database, and up to 30 business days to be reprocessed.
    Action: Go to the Electronic Transactions section of Medica.com to access the form and related information. Please note that there is no charge to providers for the registration and submission of Medica electronic transactions. You will be required to register on the web-site in order to access and begin submitting electronic transactions. If you have previously registered, you will not be required to register a second time.

    For additional information regarding the submission of On-Line Claim Adjustments, contact the Provider Service Center toll free at 1-800-458-5512. The Medica Electronic Commerce department is also available to answer questions regarding HIPAA-compliant transactions. You may contact Medica’s Electronic Commerce department via e-mail at medica.electroniccommerce@medica.com.
    Date: 1/17/2006
    Description: Medica.com Tools and Forms Updates
    Alert: The following documents have recently been either added or updated:
    • 2006 Medica Prepaid Medical Assistance and Prepaid General Assistance Certificate of Coverage
    • 2006 Medica Minnesota Care Certificate of Coverage
    • 2006 Medica Minnesota Senior Care Certificate of Coverage
    • MHCP - Overview of Benefit Changes Effective 1/01/06
    • Patient Choice Product Grid (Fall 2005)
    • University of Minnesota Fact Sheet
    Action: Please remember to check the Tools and Forms and Products pages on www.medica.com for the most up-to-date provider resource materials. For additional information, visit www.medica.com, then Provider Resources or contact the Medica Provider Service Center at: 952.992.2232 or toll-free 1.800-458.5512.
    Date: 1/03/2006
    Description: Medica Updates Utilization Management (UM) Policy, Gastrointestinal (GI) Surgery for Morbid Obesity
    Alert: Beginning January 1, 2006, updated medical necessity criteria for bariatric surgical procedures will become effective. Major updates include:
    1. Documentation of diet and exercise program participation is not required for patients with a BMI greater or equal to 55 within the year preceding surgery
    2. For patients with a BMI less than 55, participation in either:
      1. A physician-supervised weight loss, nutrition, and exercise program, or
      2. A multidisciplinary bariatric surgical preparatory program
    See Medica’s UM policy, GI Surgery for Morbid Obesity, for specific program-related criteria.

    Note: For Medicare products, providers should consult Medicare national and/or local coverage policies for information regarding coverage.
    Action: The complete text of the UM policy is available on www.medica.com in the “Provider Resources” section under “Medical Policies”.
    Updated: 5/01/2006
    Date:     1/01/2006
    Description: Medica begins new business platform for a limited number of new employer groups
    Alert: As of January 1, 2006, Medica began using a new business platform, referred to as the United Platform, for a limited number of new self-insured employer groups. This new platform will upgrade Medica’s current system capabilities and will allow Medica to be flexible and adaptable to future needs, as well as provide the ability to support new product offerings. Currently, the majority of business will remain on COSMOS – the existing platform. Going forward, Medica anticipates migrating additional commercial business to the United Platform.
    Action: Please refer to the Medica Provider Question and Answer and the Medica Provider Fact Sheet regarding the migration to the United Platform. Both documents are located on medica.com, under Provider Resources, then General Tools and Forms. Additional information will be provided as it becomes available.
    Update: The Provider Fact Sheet has been replaced by new group specific information: Target Fact Sheet (4/06) and UHC Fact Sheet (4/06).  These documents are located on medica.com, under Provider Resources, then Products.
    Products Impacted: United HealthCare, self-insured employer group #168504
    Update: Target, self insured employer group # 185002
    Date: 12/29/2005
    Description: Provider Service Center Survey
    Alert: In an effort to continually improve our service, the Provider Service Center would like to solicit your feedback by offering the Provider Service Center Survey on medica.com. Please take a moment to visit the General Tools and Forms page under the Provider Resources - Tools and Forms navigation on medica.com, or click on the PSC Survey link above.
    Action: Give us your feedback.
    Date: 12/28/2005
    Description: Actonel to be removed from Medica’s formulary, effective February 1, 2006
    Alert: Effective February 1, 2006, the osteoporosis medication Actonel will be non-formulary for all Medica members. Fosamax will be the Medica preferred bisphosphonate. Medica members who have a recent Actonel claim prior to February 1, 2006, will be grandfathered to allow time for those members to contact their physicians.
    Action: Please forward this information to your medical staff, as appropriate. Providers may check online for ongoing changes to the Medica Drug Formulary (click on “Formulary Updates”). The full Medica Drug Formulary is available there also.
    Date: 12/22/2005
    Description: UHC system edit is now in place for LaborCare lab claims using the -90 modifier
    Alert: In July 2005 Connections and September 2005 Provider Alert, it was announced that UnitedHealthcare had indefinitely delayed implementation of a system edit for claims from provider offices with reference lab charges (using the -90 modifier). UHC has been adjusting claims on a monthly basis that were denied due to the use of this -90 modifier. However, UHC now has a system edit in place that will allow LaborCare claims with this modifier to be paid the first time through (provided there is no duplicate claim from an outside laboratory). This edit went into effect December 12, 2005.
    Action: No action is necessary.
    Date: 11/28/2005
    Description: Medica Removes Prior Authorization Requirement for Endovenous Ablation for Varicose Veins
    Alert: Effective December 1, 2005, prior authorization will no longer be required for endovenous radiofrequency or laser ablation for varicose veins and chronic venous insufficiency (e.g., VNUS Closure System). Medica will continue to monitor utilization of the procedure and may conduct claim audits. Endovenous ablation is used for patients with medically significant varicose veins, greater saphenous vein incompetence and reflux at the saphenofemoral junction.
    Note: For Medicare products, providers should consult Medicare national and/or local coverage policies for information regarding coverage.

    As of December 1, 2005, the complete text of the utilization management (UM) policy that applies to this procedure (“Endovenous Radiofrequency or Laser Ablation for Varicose Veins and Chronic Venous Insufficiency”) will be available on www.medica.com in the “Provider Resources” section under “Medical Policies” (or through this link: http://provider.medica.com/C9/MedicalPolicies/default.aspx).
    Date: 11/18/2005
    Description: Referral Status Inquiry Now Available on Medica.com
    Alert: The Referral Status Inquiry Transaction allows both primary care provider and specialty clinic offices the ability to perform Administrative Referral inquiries on Medica.com. This transaction will allow provider offices to verify that an Administrative Referral has been submitted for Medica’s gatekeeper products: Advantage Plan, Medica Elect, Essential and MSHO. This transaction will display Administrative Referrals entered via Medica.com, submitted via fax, as well as through other clearinghouses.
    Action: Log on to Medica.com “Electronic Transactions” in the Provider Resources Section.
    Products Impacted: Advantage Plan, Medica Elect, Essential, Minnesota Senior Health Options (MSHO).
    Date: 11/03/2005
    Description: Update - System error causing inappropriate 251 denials for lab services submitted by a reference lab on a UB-92 claim form
    Alert: Medica has discovered that some claims submitted for Part B lab services for our Prime Solution product (group numbers 70200 - 70599) are inappropriately denying on UB92 claim submissions. Medica has corrected the system error causing the incorrect denials going forward. Medica is currently reviewing claims to determine if adjustments are necessary. Please keep in mind in some cases the 251 denial is appropriate and adjustments will not be necessary. To determine whether adjustments are needed, Medica is researching each individual claim to determine if the denial was incorrect based upon the CMS and WPS policy criteria. If providers are questioning why a claim may not have been adjusted, please reference the CMS and WPS websites for clarification of policy criteria. If after this step has been taken and a provider is still questioning why their claim was not adjusted, please contact Medica’s Coding department. Due to the manual process involved in reviewing these claims against the Medicare policy criteria, claim adjustments are taking longer than anticipated. All adjustments will be completed by November 30, 2005.
    Action: No action needed at this time. Providers DO NOT need to submit adjustment requests.
    Date: 10/27/2005
    Description: Email responses from the Coding Question mailbox
    Alert: Our goal within Medica’s Coding Administration department is to maintain a seven calendar day turn-around-time to answer and resolve your questions. With the January 2006 annual code updates fast approaching, the majority of our focus for the remainder of the year will be on reviewing these codes and making the appropriate updates to the claims system. Updates will be communicated via Connections as well as posted on medica.com. Due to this, coding question resolution may exceed the targeted seven calendar day turn-around-time. Medica appreciates your patience and understanding during this period. If your issue is of an escalated nature and you have not received resolution from Medica’s Coding department, please contact Liz Herstein, Manager, Operations, at 952-992-3107 or liz.herstein@medica.com.
    Date: 10/27/2005
    Description: Online Prior Authorization now available
    Alert: Medica is pleased to announce the availability of the new electronic transaction for prior authorization (transaction 278), Health Insurance Portability and Accountability Act of 1996 (HIPAA).The transaction is now available for Medica providers via www.Medica.com. Providers may access this by using the “Provider Resources” drop-down menu and selecting “Electronic Transactions.” Any supporting documentation required will need to be submitted by fax to 952-992-3556 or 952-992-3554.
    Date: 10/10/2005
    Description: CPT Coding for Recently Approved Vaccines
    Alert: Medica will be accepting the following Current Procedural Terminology (CPT) codes for the recently FDA approved vaccines across all products, unless otherwise noted:
    • 90710 – measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use ( ProQuad )
      • For Medica Choice CareSM and Medica MinnesotaCare Products – please submit 90707 (MMR) and 90716 (Varicella virus) until further notice
    • 90733 – meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use ( Menomune )
    • 90734 – meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use ( Menactra )
    Date: 9/19/2005
    Description: FluMist to be Covered for Health Care Workers Who Provide Direct Patient Care
    Alert: Effective October 1, 2005, Medica will cover FluMist™ as a covered benefit for Medica members who are health care personnel providing direct patient care. This policy change is due to the uncertainties in doses and distribution of the injectable influenza vaccine, as indicated by the Centers for Disease Control and Prevention (CDC). More details about this update are available online at the CDC Web site. Providers may refer to the full Medica coverage policy, “Influenza Virus Vaccine, Live, Intranasal - FluMist™,” on www.medica.com in the “Provider Resources” section under “Medical Policies.”
    Action: Providers who have questions or comments about Medica’s flu prevention program may call Noel Goldman, quality improvement program coordinator at Medica, at 952-992-8493.
    Date: 9/08/2005
    Description: UHC continues reprocessing claims that were denied due to -90 modifier edit
    Alert: As previously reported (March 2005 Connections; May 2005 Provider Alert), UHC continues to hold off on implementation of the -90 modifier edit for LaborCare claims. They are running monthly reports for claims that were denied during the previous month due to this edit.
    Action: No requests for adjustments are required by providers; UHC will automatically reprocess all claims that were denied due to the -90 modifier edit.
    Date: 9/07/2005
    Description: System error causing inappropriate 251 denials for lab services submitted by a reference lab on a UB-92 claim form
    Alert: Medica has discovered that claims submitted for Part B lab services for our Prime Solution product (group numbers 70200 - 70599), are inappropriately denying. Medica has corrected the system error and will run a report to identify all the affected claims to be reprocessed for reimbursement.
    Action: No action needed at this time. Providers DO NOT need to submit adjustment requests.
    Date: 9/06/2005
    Description: Some PRAs May Reflect Duplicative Claims When Member Claims Histories Switched Over to New Secure 'Alt ID' Numbers
    Alert: During the September-October 2005 timeframe, providers may receive provider remittance advices (PRAs) that appear duplicative for provided services and include $0 amounts. This will be a result of Medica undergoing a manual initiative for commercial groups to switch a member's claims history from a member's Social Security number (SSN) to a new secure "Alt ID" member number, after which related claims are re-entered into Medica's claims system under the new Alt ID.
    Action: Providers are encouraged to cross-reference the member name and patient account number for the affected Medica claims to verify that appropriate payment is received from Medica. Actual provider payments should not be affected by this manual Alt ID switch-over process as Medica synchronizes prior SSNs to Alt IDs.
    Date: 9/01/2005
    Description: Submitting Claims Electronically for SelectCare and LaborCare
    Alert: WebMD is now accepting institutional claims by electronic submission. This applies to the SelectCare and LaborCare non-remote repricer, payer ID 00014. Providers who are interested in submitting their institutional claims electronically for payer ID 00014 should work with their vendor to determine claims submission capabilities with WebMD or work directly with their WebMD account representative.

    Electronically submitted claims are turned around faster and generally are more accurate than those submitted on paper claim forms. Therefore, SelectCare and LaborCare providers are encouraged to submit their claims electronically for institutional and professional claims.

    For more information on submitting claims, providers may refer to the SelectCare and LaborCare Provider Administrative Manual located on www.medica.com in the “Provider Resources” section under “Administrative Manuals” (or through http://provider.medica.com/C7/ProviderManualCare/default.aspx). Providers may also contact Medica’s Electronic Commerce department by e-mail at medica.electroniccommerce@medica.com.
    Date: 8/05/2005
    Description: Medica.com system issue
    Alert: There are problems connecting with UHG-B2B for the medica.com provider transactions. Efforts are under way to get this resolved. No ETA at this time.

    This UHG-B2B problem may also impact other sites using the B2B for transactions, such as Claimlynx and WebMD. Providers should work with their Practice Management System or clearinghouse vendor. The vendor will then escalate to UHG as needed.
    Date: 7/28/2005
    Description: FluMist™ (Influenza Virus Vaccine, Live, Intranasal)
    Alert: Medica will not cover FluMist™, the intranasal live influenza vaccine, due to the availability of a safe and effective alternative. The injectable vaccine for influenza continues to be covered. In the event of a sudden, serious influenza vaccine shortage, Medica will cover FluMist™ per Minnesota Department of Health guidelines. Should this become necessary, you will be notified via the ALERT process and be directed to an updated coverage policy. Medica’s current policy is attached for your review.
    Date: 7/25/2005
    Description: Medica.com Administrative Referral Transaction Default Care Level Updated
    Alert: The default “Care Level” for Administrative Referrals entered via Medica.com has been changed from “Care Level 3: Consult, Diagnose & Treat” to a “Care Level 2: Consult & Diagnose”.
    Action: The default care level will be Care Level 2 – Consult and Diagnose only when no Care Level is indicated on the Administrative Referral Transaction via Medica.com.
    Reminder: Care Level 3 referrals authorize a specialist to order additional services without an Administrative Referral (i.e. PT/OT/ST, DME, MRI, CT Scan, Out-Patient surgery, etc…)
    Products Impacted: Medica gatekeeper products: Advantage, Elect, Essential, MSHO
    Date: 7/21/2005
    Description: 3rd Quarter CPT and HCPCS Code Information, Bilateral Policy Update and Consultation Service by a Physician Assistant
    Alert: Obtain information on the 2005 codes effective 7-1-2005, Bilateral Policy Update and submission of consultation services by a physician Assistant!
    Action: Information can be found at Coding Tools and Forms and at Reimbursement/Claim Policies under the Provider Resources / Tools and Forms navigation.
    Date: 7/14/2005
    Description: Medica Electronic Provider Remittance Advice (EPRA) Successful Conversion to ANSI X12 835, v.4010A1
    Alert: Medica successfully completed the EPRA conversion to ANSI X12 835 v4010A1 on 7/13/05. All EPRA recipients will now receive the HIPAA 835, v4010A1. Older formats or versions of the EPRA will no longer be supported.

    Enrollment activity for add, changes and deletes for EPRA will resume beginning 7/14/05.

    For additional information, the 835 v.4010A1 Implementation Guides can be found at www.wpc-edi.com. Reference materials on Medica’s implementation of EPRA including an 835 Companion Guide, can be found in Chapter 21 of the Medica Admin Manual, available online under Provider Resources at www.medica.com. As a reminder, all EPRA receivers will continue to receive the paper remittance as a back up and an audit trail. Recipients of EPRA files are solely responsible for ensuring that appropriate audit and accounting practices are in place within their organization to handle automated posting of EPRA.

    For questions pertaining to file names or file delivery, contact your Clearinghouse or Practice Management System vendor directly.

    Other questions or issues may be addressed to Medica Electronic Commerce.
    Date: 7/11/2005
    Description: Problem identified with EPRA delivery (835 files)
    Alert: It is been identified that between the dates of 6/25/05 and 7/05/05, not all Medica EPRAs successfully reached their intended clearing house, Claimlynx, WebMD or ProxyMed. A system fix has been put in place. Medica’s claim processing vendor has identified all impacted provider sites. All missing EPRA files will be recreated and distributed Monday night, 7/11/05.
    Action: None at this time. Medica’s vendor will be contacting all affected clearing houses.
    Date: 7/01/2005
    Description: Medica addresses partial Minnesota government shutdown
    Alert: Please review Medica’s intention with regard to claims submitted for services provided to its State Public Programs (SPP) members during the partial Minnesota government shutdown.
    • Medica will continue to provide health benefits to its SPP members under the terms and conditions specified in its contract with the Minnesota Department of Human Services (DHS) and any subsequent amendments.
    • Medica will pay all submitted claims for covered services with dates of service through July 31, 2005.
    • As long as Medica receives its capitated payments from DHS prior to July 31, 2005, there won’t be any interruption in coverage. If capitated payments aren’t received, Medica reserves the right to consider its options under the DHS contract. If Medica elects to take a different course of action after July 31, 2005, providers will receive advance notice of Medica’s decision.
    Action: None at this time.
    Products Impacted: Medica Choice Care, Medica MinnesotaCare (Group Numbers: 59000 – 59999).
    Date: 6/10/2005
    Description: EPRA conversion date set
    Alert: Medica is scheduling a conversion to the ANSI X12 835 v.4010A1 format for electronic provider remittance advices (EPRAs). Medica plans to implement this EPRA migration on July 13, 2005. Older formats or versions of the EPRA will no longer be supported after this conversion. As specific dates are determined, Medica will notify providers through Provider Alerts and Medica Connections. Enrollment activity for additions, changes and deletions for EPRA will be suspended during the migration process, June 29 – July 13, 2005, to support this conversion.
    Action: Ensure your system is ready to accept the HIPAA compliant 835 (EPRA) transaction on July 14, 2005.
    Plans Impacted: All.
    Date: 6/07/2005
    Description: Claims for Menards employees, group # 707866, Denying Reason Code 51, After Member Exp Date
    Alert: Medica has identified a system set up error that caused Menards employee claims to inappropriately deny as After Member Expiration Date. This error affected claims entered under group number 707866 with dates of processing 5/11 through 5/17.
    Action: No action needed by the provider. Medica is running reports to identify all impacted claims and will reprocess claims accordingly. Please allow 30-60 days for adjustments to occur.
    Plans Impacted: Passport, Menards group number 707866.
    Date: 5/24/2005
    Description: WebMD to discontinue the remaining Medica pre-HIPAA proprietary transactions and offer only the HIPAA versions
    Alert: As of June 30, 2005, WebMD will discontinue the remaining Medica pre-HIPAA proprietary transactions and only offer the HIPAA versions. The transactions affected are claim status inquiry, claim adjustments, referral request, and referral inquiry.

    278 – Referral Request
    The administrative referral transaction will be available for Medica gatekeeper products: The Advantage Plan, Medica Elect, Medica Essential, and Medica Premier. Referral inquiry will no longer be a feature available via WebMD. The referral status inquiry is not a HIPAA mandated transaction therefore WebMD removed this functionality.

    276/277 – Claim Status Inquiry
    The HIPAA-compliant version has different data requirements from the proprietary version.. A Quick Reference Guide is available on Medica.com, Provider Resources, Administrative Manuals, Medica Provider Manual, Chapter 21, Appendix W to assist providers with completing the HIPAA compliant version of the 276 transaction. It provides a screen shot from WebMD along with a table explaining each field.

    WebMD will no longer accept electronic adjustment requests. The following options are available to providers:
    Submit a paper adjustment request form to the following address:

    Medica (all products except DUAL solution)
    Mail Route 2901
    PO Box 659752
    San Antonio, TX 78265-9752

    Medica DUAL Solution
    Mail Route 2902
    PO Box 659752
    San Antonio, TX 78265-9752
    If the entire claim denied and nothing was allowed on any detail line, resubmit the entire claim electronically.
    Work with an electronic data interchange (EDI) vendor to explore other clearing houses that accept EDI adjustment requests.
    Medica is developing online claim adjustment capabilities which could be available this fall.

    As a reminder the non-HIPAA version of the 270/271 – Eligibility Inquiry and Response transaction is no longer available as of 3/4/05.
    The HIPAA version allows for the following search capabilities and associated responses: 
    • Subscriber ID 
    • Subscriber Social Security Number 
    • Subscriber name, date of birth (DOB), and state 
    • Subscriber ID, dependent name, and DOB 
    • Dependent name, DOB, and state 
    • Dependent SSN
    The following features are no longer available on the HIPAA version: 
    • Member’s coverage history – HIPAA does not accommodate coverage history so providers will need to include the specific date of service within the transaction. 
    • Subscriber’s dependents – HIPAA does not accommodate displaying family members. HIPAA guidelines allow providers to only search for one member at a time. The member can be the subscriber, the spouse or the dependents.
    Medica has worked to provide providers options from which they can conduct electronic transactions. Please refer to Medica’s document titled Other Electronic Options for Providers located under the Electronic Transactions header on the General Tools and Forms page within the Provider Resource section of www.medica.com. This document identifies options providers have available. Questions on the HIPAA transactions may be directed to Medica’s Provider Service Center or the Electronic Commerce department at medica.electroniccommerce@medica.com.

    Please note the above information will also be published in the June 2005 Connections. 

    Products Impacted: All
    Date: 5/5/2005
    Description: UHC Defers Implementation of -90 Modifier Edit for LaborCare Claims
    Alert: In the March 2005 edition of Connections, it was announced that UnitedHealthcare (UHC) was going to delay implementation of its pass-through lab billing system enhancement until March 1, 2005 for LaborCare claims. However, UHC has now made the decision to indefinitely delay implementation of this -90 modifier edit for LaborCare claims. UHC will continue to review the edit, but in the meantime, they have initiated a claims project to reprocess any claims that have been denied due to the -90 modifier edit. The first phase of the claims project included claims that were processed from December 1, 2004 through February 28, 2005. Starting April 1, UHC will run monthly reports for denials processed during the previous month.
    Action: No requests for adjustments are required by providers; UHC will automatically reprocess all claims that were denied due to the -90 modifier edit.
    Date: 5/2/2005
    Description: 2nd Quarter HCPCS and Bilateral Policy Update Information Posted on Medica.com
    Alert: Obtain information on the 2005 HCPCS codes effective 4-1-2005 and the Bilateral Policy Update now on Medica.com!
    Five documents have been posted to provide an overview of the updates:
    1. 2005 HCPCS Code Update - 2nd Quarter
    2. 2005 Medicare PET Scan Code Changes
    3. 2005 Medicare "Q" Code Changes
    4. 2005 ICD-9-CM Code Update and Coding Guidelines
    5. 2005 Bilateral Policy Update - 2nd Quarter
    Action: Log onto www.medica.com, hover over the "Provider Resources" drop down, Tools and Forms, go to Coding Tools and Forms for the code updates, and click on the articles. Go to Reimbursement/Claim Policy Update Communication and click on the Bilateral Policy Update article.
    Date: 4/11/2005
    Description: Passport Temporary Member ID Cards list 11 digit alternative ID number in error
    Alert: As a reminder, Passport member ID cards should list a six or seven digit policy number followed by a nine digit alternative ID number.  It has been identified that the temporary ID cards issued for Passport groups effective 3/1/05 and 4/1/05 included two leading zeros in front of the nine digit alternative ID number.  Groups affected by this error include Menards, City of Hibbing, Morrell, CG Bretting, Global Electric Motor, Roisum Electric Sales, Core Product, Innovex, Bonestroo, and Bureau of Engraving.   The permanent ID cards for these groups will issue correctly and not include the leading zeros.
    Action: Please disregard the two zeros in front of the nine digit alternative ID number.
    Products Impacted: Passport
    Date: 3/08/2005
    Description: Electronic Transaction "Invalid Format" Error
    Alert: Provider offices/sites may be receiving the following error when attempting to perform Electronic Transactions on www.medica.com: "Invalid Format" when entering member date of birth (DOB), or dates of service (DOS).
    Action: Please go to the top of your browser and click on the "REFRESH" button to update to a current browser setting. As Medica continues to release website enhancements, you will periodically be required to repeat this action. This action insures that your computer is not relying on cached files.
    Products Impacted: Eligibility Transactions: Administrative Referral Transaction, Admission Notification Transaction
    Updated: 5/24/2005
    Date:     2/23/2005
    Description: Physician Claims Inappropriately Denying Reason Code 617, Non-Covered Hearing Aids
    Alert: Medica has identified a system set up error that caused all CMS-1500, physician claims to inappropriately edit and deny as non-covered hearing aids (denial reason code 617). This impacts all claims entered on 2/23/05.
    Action: No action is required by the provider. Medica is running reports to identify and reprocess affected claims. Please allow 30- 60 days for adjustments to occur.
    Update: Medica has determined this issue has affected claims dating back to 02/14/05. Medica has identified all affected claims entered between 02/14/05 and 2/23/05. All claims will be reprocessed accordingly.
    Date: 2/22/2005
    Description: Preservative Free Tetanus and Diphtheria Vaccine
    Alert: CPT has released a new code, 90714, that will be effective 7-1-05 for the Preservative Free Tetanus and Diphtheria vaccine for individuals 7 years and older. Since the preservative free vaccine is available at this time, for dates of service 1-1-05 through 6-30-05, unlisted vaccine CPT code 90749 may be submitted. With the submission of the unlisted code, a description of "Decavac" or "Preservative Free Td" must be on the claim for correct processing.
    Products Affected: All
    Date: 2/11/2005
    Description: Medicaid claims incorrectly denied with reason code 633 "Durable Medical Equipment, Not Covered"
    Alert: Medica recently identified a system set-up error which caused Medicaid claims to deny in error - with reason code 633 "Durable Medical Equipment, Not Covered" on non-DME services. This affects claims with a date of processing or entered date of 1/28/05-2/1/05.
    Action: No action needed by the provider. Medica is running a report to identify and reprocess impacted claims. Please allow up to 30-45 days for reprocessing.
    Plans Impacted: Medicaid, group numbers 59525, 59725, 59825.
    Date: 1/31/2005
    Description: Eligibility Inquiries available on Medica.com
    Alert: Electronic transactions for member eligibility status (transactions 270/271), compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), are now available through www.medica.com for Medica providers. Providers are encouraged to log onto www.medica.com and register their site in order to begin using this feature.

    As previously noted, there is no charge to providers for the registration and submission of Medica electronic transactions. Providers will be required to register in order to access the secure site and begin verifying member eligibility. It is not necessary for a provider site to register a second time if previously registered.
    Action: Once on Medica's website, hover over Provider Resources and scroll down to Electronic Transactions. By clicking on Electronic Transactions you will access the Provider Resources Login page.
    Date: 1/28/2005
    Description: Claim Submission For Medica MHCP Newborns
    Alert: Effective for newborns born on or after October 1, 2004, the Minnesota Department of Human Services (DHS) began enrolling newborns into the same health plan as the mother for Minnesota Health Care Programs (MHCP) enrollees on Medical Assistance and MinnesotaCare (59XXX group numbers). Please submit the newborn's paper or EDI claim under the mother's Medica Member ID number, excluding the two digit relationship code. Include the baby's date of birth and name in the patient information vs. the mother's date of birth and name. Providers are urged to use the DHS Eligibility Verification System (EVS) to verify the mother's health plan coverage by accessing EVS online at http://www.mnevs.state.mn.us/.
    Products Impacted: Medica Choice Care and Medica MinnesotaCare members.
    Date: 1/28/2005
    Description: Alternative ID Numbers For Medica’s New Passport Product and WebMD
    Alert: With the implementation of Phase 2 for Medica’s new Passport product, effective 1/1/05, every Passport member that receives a Health Care Account Card (HCAC) will be issued an alternative ID number. The Passport member number consists of a 6 or 7 digit group number plus a 9 digit alternative ID number. For those providers utilizing WebMD to verify eligibility, you must use the HIPAA-version transaction to access the alternative ID

    In the November, 2004, edition of Medica Connections, we encouraged providers to begin using the HIPAA-version of WebMD immediately.  If you are continuing to use the pre-HIPAA version to check eligibility on Passport members, you will see a 16 digit member number (a 5 digit group number, 9 digit ID number and 2 digit relationship code), which will be different than the member's number on their HCAC card.  The date this version will be discontinued will be communicated to the provider network as soon as it is determined.
    Action: To ensure you are using the HIPPA-version of WebMd to verify eligibility, select "Medica Health Plans HIPAA Initiative", when you choose the payer you want to perform eligibility for (it sits right below Medica Health Plans). To ensure correct processing of your claim, submit your claim with the group number and alternative ID number that is printed on the member’s HCAC card.
    Product Impacted: Passport
    Date: 1/25/2005
    Description: For LaborCare Network, UHC Defers Implementation of Pass-Through Lab Billing Until March 1, 2005
    Alert: The following article was published by UnitedHealthcare (UHC) in its November 2004 Network Bulletin:

    Pass-Through Billing System Enhancement

    "Under the terms of our standard participation agreements, physicians, practitioners and medical groups may only bill for services that they or their staff perform. Pass-through billing of ancillary services such as radiology and laboratory services that are ordered by the physicians, but performed by an outside company, are not reimbursable under those agreements. Moreover, when physicians submit claims for ancillary services performed by outside companies, double billing often occurs, increasing administrative costs for UnitedHealthcare, our ancillary provider network, and our enrollees.

    "In November 2003, UnitedHealthcare updated its Outpatient Laboratory Services Management Program, which is posted on the physician Web site, www.unitedhealthcareonline.com, to highlight that physicians who send specimens to an outside laboratory for processing should not bill UnitedHealthcare for these laboratory procedures. The laboratory performing the service is required to bill UnitedHealthcare directly. Additionally, in January 2004, UnitedHealthcare sent a letter to Primary Care Physician offices alerting those practitioners about how we pay for ancillary services and the terms of their contracts with us. Finally, in May 2004 UnitedHealthcare updated the Administrative Guide to focus physicians' attention on these billing requirements.

    "Starting in December 2004, we will now have the ability to automate the contractual requirement that physicians and other health care practitioners only bill for laboratory services they or their staff perform. Specifically, a system enhancement in December will deny laboratory services reported by a physician office with a modifier -90, which indicates the laboratory service was performed by an outside reference laboratory. If the physician office has performed the laboratory service on-site and has not sent it to an outside laboratory, the office should bill without the modifier 90."

    Action: In order to allow adequate time for LaborCare providers to adjust for this change, UHC has agreed to defer implementation of this enhancement until March 1, 2005. Any claims incurred or processed December 1, 2004, through February 28, 2005, that were billed with the –90 modifier and were denied by UHC will be reprocessed by UHC. No requests for adjustments are necessary; UHC will automatically adjust all such claims beginning April 1, 2005.
    Date: 1/12/2005
    Description: 2005 CPT and HCPCS Code Update Information Posted on Medica.com
    Alert: Obtain information on the new 2005 CPT and HCPCS codes now on Medica.com! Four documents have been posted to provide an overview of the updates to the code sets that were effective January 1, 2005, dates of service: (1) 2005 CPT Code Update, (2) 2005 HCPCS Code Update - 1st Quarter, (3) 2005 HCPCS Crosswalk Grid - 1st Quarter, and (4) 2005 Medicare “G” Codes.

    Action: Log onto www.medica.com, hover over the "Provider Resources" drop down, go to Tools and Forms, Coding Reference Materials and click on the articles.
    Date: 1/1/2005
    Description: Northwest Airlines Membership Moves to Passport Utilizing the Medica Choice Network
    Alert: Administrative Referrals are no longer required for Northwest Airlines (NWA) members. Because the Medica Choice network is an open access plan, the members are not required to choose a Primary Care Provider/Clinic. NWA members are subject to the Prior Authorization, and Care Availability guidelines and requirements for Medica Choice as it pertains to access to non-contracted providers. The Prior Authorization, and Care Availablity guidelines can be found on Medica.com, Provider Resources, Medical Policies.

    Action: Verify Member Eligibility and Benefits by calling the Provider Service Center at: 952-992-2232 or toll free at: 1-800-458-5512.
    Plans Impacted: Passport, group number 185283
    Date: 12/28/2004
    Description: Temporary Passport Identification Cards
    Alert: A select group of Medica Passport members, tier 2/4 groups, are at risk of not receiving their Health Care Account Card prior to their effective date. Medica has produced temporary ID cards for the specified groups. Members have been asked to use the letter as a temporary identificaiton card until they receive their "true card." Please click on the the following links to view a sample of the letter.

    Medica Sample Letter
    UHC Sample Letter
    Multiplan Sample Letter

    For addtional information on the HCAC please refer to Connections, November 2004 p. 16-17 and December 2004 p. 18-19.
    Action: Please accept information on the letter as you would information on a standard ID card.
    Plans impacted: Passport.
    Date: 12/21/2004
    Description: Update to coverage decision on botulinum toxin (BTX)
    Alert: Medica has re-reviewed the coverage policy on botulinum toxin (BTX) effective 12/1/04. After careful consideration, Medica has determined that it will cover BTX for any non-cosmetic indications retroactive to December 1, 2004. Claims for any use of BTX for cosmetic diagnoses will continue to be denied. Medica will review the clinical evidence on the safety and effectiveness of BTX regularly and will determine whether any changes based on that evidence are warranted in the future.

    A report will be generated to reprocess the eligible denied claims received 12/1/04 date of service and after. Affected members will receive a letter notifying them of the change to our policy. An updated coverage policy will be posted on medica.com shortly.
    Action: None at this time.
    Plans impacted: All products except for Prime Solution.
    Updated: 12/17/2004
    Date: 12/09/2004
    Description: Changes To Flu Vaccine Guidelines
    Alert: There have been changes to the guidelines for patients eligible to receive flu shots. As of Dec. 1, vaccine is now available for people who fall into the following risk groups:

    - All adults age 50 and older (previously, vaccine was available only to adults age 65 and older).
    - Someone who lives with or cares for those at risk for serious complications of the flu (this is a new-high risk group).

    Update: Effective Friday, December 17th, the Minnesota Department of Health opened up the Flu Shot Vaccine to anyone in Minnesota who wants one.

    Click here to view the full set of guidelines.
    Action: None required. This is an advisory alert only.
    Plans impacted: All Medica products.
    Date:11/21/2004
    Description: HIPAA 278 Transactions (Administrative Referral & Admission Notification) now available for Medica providers
    Alert: Providers can now submit Admission Notifications and Administrative Referrals directly to Medica via www.medica.com.
    Action:Log onto www.medica.com, hover over the "Provider Resources" tab, then scroll down and click on "Electronic Transactions". You will be asked to enter your username and password. If you have not previously created a username and passwork on Medica.com, you will need to register in order to access the secure Electronic Transactions site. After you have registered, you will have the ability to enter admission notification and administrative referrals. Note that referrals are only needed for the gatekeeper products: Advantage, Elect, Essential, Premier. A tutorial is available on the Electronic Transactions site. For additional information regarding the submission of Administrative Referrals and Admission Notification via Medica.com, providers may contact the Provider Data Department:

    - (Inpatient Facilities) Inpatient Admission Notification Call: 952.992.2092, option 4.
    - (PCP Clinics) Administrative Referral Inquiry Line Call: 952.992.3291.

    The Medica Electronic Commerce department is also available to answer questions regarding HIPAA-compliant transactions. Providers may contact Medica's Electronic Commerce department for questions regarding HIPAA compliant transactions via e-mail at medica.electroniccommerce@medica.com.
    Date: 10/25/2004
    Description: Administrative Referrals Are NOT Required for Flu Vaccinations
    Alert: This is a reminder that flu vaccinations do not require an Administrative Referral from a member’s Primary Care Provider. If member’s are instructed to seek the vaccine outside of their Primary Care Clinic or Care System for Medica’s gatekeeper products: Advantage, Elect, Essential, Premier, MSHO, then the member does not need an Administrative Referral to receive the flu shot vaccine.
    Action: No Action Required
    Date: 10/06/2004
    Description: CPT Code 85060 Incorrectly Denying Reason Code 93 (Modifier Required)
    Alert: An update to the Professional/Technical claim edit was implemented on July 28, 2004, date of processing. As a result of this update, code 85060 was incorrectly denying reason code 93, Modifier required, if the place of service was in a facility setting (primarily POS 21 and 22). The processing system was corrected on September 15, 2004. This code is now processing correctly with a facility setting place of service. This primarily impacts pathology providers or provider type '11'. A report will be generated to reprocess the denied claims between 7/28/04 and 9/15/04 date of processing. Please allow 45 days for the claims to be adjusted.
    Action: None at this time.
    Plans impacted: All Medica products.
    Date: 10/05/2004
    Description: Additional Issues Discovered at UHC in Processing of LaborCare Team Anesthesia Claims
    Alert: In UnitedHealthcare's (UHC's) effort to correct a problem in the processing of anesthesia claims with the -59 modifier (it was not being recognized), most anesthesia claims began passing through the iCES editing system as of August 27, 2004. It has been confirmed that use of the QS modifier caused one line to be denied as a duplicate, without taking into consideration the other modifiers QK and QX. UHC is working on a fix and a national claims project will be generated to capture the errors and adjust the claims. Please note, it is taking UHC approximately 70 days for claim project adjustments to be completed. Until the system is corrected, on-going monthly claim reports will be generated and impacted claims will be sent for adjustment.
    Action: No action is necessary. The national claims project will adjust the affected claims.
    Date: 09/24/2004
    Description: Medica's HIPAA Initiative Eligibility Transaction
    Alert: Medica's HIPAA Initiative Eligibility transaction has been available for providers since July 1. Earlier this week an enhancement was performed to respond with additional information in the Eligibility response, however, this caused the duplicate subscriber id rejection to appear. Medica is aware of this and we are working with our electronic vendors to get this fixed soon. This error will occur at both WebMD and ClaimLynx. Action: As a result of the duplicate subscriber id rejections, the pre-HIPAA Eligibility will continue to be available through WebMD so that providers can obtain the information they need in order to perform other transactions such as referral entry or claims submission. WebMD will post a flash message once this duplicate subscriber id problem is fixed. In addition, Medica will post an alert so that ClaimLynx users are aware of the fix.
    Date:09/14/2004
    Description: Correction to Phone Number for Aetna's Provider Service Line
    Alert: In the September 2004 edition of Connections, it was reported that Aetna had established a dedicated provider service line that SelectCare providers can use to reach Aetna's provider service center; however, the toll-free area code listed was incorrect. The correct number should be 1-888-MDAetna (632-3862).
    Action:For additional information about this dedicated provider line, Aetna Voice Advantage, please refer to the September 2004 edition of Connections.
    Date:08/24/2004
    Description: ProNet's Claims Address Has Changed
    Alert: SelectCare has just been notified by Provider Networks of America ("ProNet") that they changed their claims submission address as of May 2004. The new address is: PO Box 850778 Richardson, TX 75085-0778 If a provider's office has "Return Service Requested" printed on its envelopes, the claims are being returned to the provider with a forwarding address label from the Post Office. If an office has "Address Service Requested" printed on its envelopes, the Post Office will forward the claims to ProNet and notify the sender of the new address. There is a seventy cent charge per envelope for this type of service. Due to the forward they have on their mail, ProNet did not realize it was necessary to notify SelectCare or any of SelectCare's providers of the change. They will be printing the new claims address on enrollees' ID cards as their plans renew. The Post Office will be forwarding ProNet's mail for one year (until May 2005).
    Action:Please update your records with the new claims address and begin using the new address immediately.
    Date:08/03/2004
    Description: Medicaid - Claims Denied in Error
    Alert: Due to a system enrollment error, coverage for a limited amount of Medicaid members (59XXX group number) were terminated incorrectly. This resulted in all claims denying inappropriately for dates of processing 7/29/04 and 07/30/04. These members will appear on your PRA with reason code 068 (Your plan does not cover this expense). The system has been corrected. Most claims were reprocessed today and will show on today's 8/3/04 checkwrite. The incorrectly denied claim and the reprocessed claim will both appear on today's Provider Remittance Advice (PRA). For those reprocessed claims that did not make it on today's check write, the reprocessed claim will show on your next checkwrite and the denied claim only will show on todays PRA.
    Action:No action is needed.
    Date:07/29/2004
    Description: Code A6257 (Transparent film, 0-16 SQ IN, each dressing) Denying Reason Code 68 (Your plan does not cover this expense)
    Alert: We recently identified an issue with code A6257 denying incorrectly with reason code 68 for claims entered from 6/18/04-7/21/04, billed with a date of service after 1/1/02. The claim processing system was corrected on 7/22/04. A report will be run to identify all impacted claims and have them adjusted. Please allow 45 days for completion of the claim adjustments.
    Action:None at this time.
    Products affected:This issue impacts Medica's Commercial products (multiple group numbers) and Value Choice Individual plan (group numbers 08XXX). Plans excluded and NOT impacted by this issue are Medica's Prime Solution (group numbers 70XXX), Medica's Select Solution (group numbers 71XXX) and MCHA Senior plans (group numbers 718XX).
    Date:07/29/2004
    Description: HIPAA 270/271 Eligibility Transaction Now Available For Medica
    Alert: Medica Health Plans is pleased to announce the new HIPAA compliant 270/271 Eligibility Inquiry transaction is now available in WebMD Office. We encourage you to begin using the HIPAA 270/271 Eligibility immediately.

    Current users of WebMD Office will see a 'flash message' on the Office home page and will be able to select the 'Medica HIPAA Initiative' Eligibility transaction from the menu. New users can go to www.webmdenvoy.com to learn more about WebMD Office and begin the registration process.

    This HIPAA compliant transaction replaces the existing, proprietary eligibility inquiry currently offered in WebMD Office. The proprietary eligibility transaction will be discontinued on October 1, 2004.

    Medica encourages users to provide WebMD with feedback regarding your experiences with the new 270/271 Eligibility transaction. Please send feedback to officefeedback@webmd.net or direct questions to the WebMD Help Desk at (877) GO WEBMD/(877) 469-3263.

    Medica Electronic Commerce is also available to answer questions regarding HIPAA compliant transactions. Contact our E -Commerce Department at medica.electroniccommerce@medica.com.
    Updated: 9/20/04
    Date:07/16/2004
    Description: UnitedHealth Networks has identified certain obstetrical anesthesia services that are being improperly reimbursed
    Alert: It was recently identified by UnitedHealth Networks (UHN) that obstetrical anesthesia services 01960, 01961, 01963, 01968, and 01969 are not being reimbursed because the system is inappropriately applying non-notification processing to these services. This affects claims that were processed during the time period of January 1, 2003 until the present.
    Action:UHN will have all impacted claims adjusted automatically, so there is no need to resubmit these claims or request adjustments. They are also working on a system update, so this does not continue to occur. After the system update, if there are any claims that were not adjusted, please submit those requests through unitedhealthcareonline.com.
    Update: UHN is still in the process of working on a system correction and will continue to automatically adjust all impacted claims until the system fix is in place. Medica will continue to provide updates until this issue is resolved.
    Products affected: LaborCare only
    Date:06/13/2004
    Description: Utilization Management (UM) Policy III-MED.04, Cancer Clinical Trial Participation, Coverage of Routine Supplies and Services - Administrative Update
    Alert: Effective August 1, 2004, prior authorization for coverage of routine supplies and services associated with participation in a cancer clinical trial is no longer required of in-network oncologists. Prior notification of the member’s intended participation in a cancer clinical trial is required, and can be accomplished by submitting the Prior Notification for Participation in a Cancer Clinical Trial form at the time the member is enrolling in the trial. This form is located within UM Policy III-MED.04, which is found on www.medica.com in the Provider Resources, Medical Policies section. Medica requests a copy of the trial consent form upon receipt of the member’s signature, but the form does not need to be submitted prior to trial participation.

    Oncologists outside Medica’s network are still required to follow Medica’s prior authorization process for review of coverage of routine supplies and services associated with a request for member participation in a cancer clinical trial. Medical necessity criteria are applied as set forth in UM Policy III-MED.04. Medica’s written approval of coverage of routine supplies and services associated with an out-of-network request must be received by the out-of-network oncology group or facility prior to member participation.

    In both cases, coverage levels for routine supplies and services will be determined in accordance with the member’s coverage document.
    Date:06/10/2004
    Description: Payer Responsibility Changes for the 70XXX Prime Solutions Product for Home Care and Infusion Services
    Alert: The Centers for Medicare and Medicaid Services (CMS) has changed payer responsibility for Home Care and Home Infusion services for Medica Prime Solution members (group number beginning with 70XXX). Effective July 1, 2004 dates of service, Medicare will become primary payer vs Medica for all home health care services billed on a UB92 under a 59XXX provider number as well as all home infusion nursing services billed on a CMS 1500 under a 60XXX provider number. Other home infusion services such as drugs and equipment charges should still be sent to Medica as the primary payer as CMS considers these services DME and/or pharmacy charges.
    Date:06/08/2004
    Description: 52 Modifier Rejection
    Alert: Medica identified an issue with the 52 modifier. From 4/24/04 to 5/3/04 dates of processing, CPT codes 10000-99999 billed with a 52 modifier were being rejected. Claims were NOT denied in our claim processing system resulting in a denial reason code returned on the Provider Remittance Advise. Rather, impacted claims were returned to providers with a send-back letter. The reason on the send-back letter states "Modifier invalid - 52 modifier is invalid for date of service".
    Action:The system was updated on 5/3/04 and providers should re-submit any claims that were rejected as impacted claims were not retained in our system but rather returned to providers.
    Date:05/19/2004
    Description: New 251 Denial Issue Identified
    Alert: An issue has been identified where all hospital and physician claims are denying inappropriately for denial reason code 251 for date of processing 5/7/04, unless the claim is billed with a diagnosis range of 401.00-402.9. Claims with this diagnosis code range are not impacted by this issue. The system has been corrected and approximately 12,075 claims were denied incorrectly. All impacted claims have been sent for adjustment. Please allow 30 days for the adjustments to be processed.
    Action:No action is needed at this time.
    Date:05/07/2004
    Description: WebMD Office Location Change On WebMD Home Page
    Alert: A change to the location of WebMD Office on the WebMD home page was recently identified. To access WebMD Office, click on the "WebMD Envoy" button where the WebMD Office button use to be. Then scroll down to the bottom of the page that is displayed and click on Log in under WebMD Office.
    Action:No action is needed at this //time.
    Date:05/04/2004
    Description:4th quarter 2003 PCR checks programming error
    Alert:4th quarter PCR checks were mailed the week of 4/26/04. Due to a programming/server error, these checks were incorrectly generated using the 3rd quarter 2003 PCR amounts. The result is some overpayments and underpayments depending on the difference in the providers allowed volume between the 3rd and 4th quarters in 2003. For the underpayments, checks in the amount of the difference will be mailed in 1 to 2 weeks with the necessary supporting information. For the overpayments, the difference will be offset against the 1st quarter 2004 PCR return. Additional information on the overpayments will also be mailed in 1 to 2 weeks.We are making every effort to quickly resolve this discrepancy and apologize for any inconvenience that this may have caused your office.
    Action:No action is needed at this time.
    Date:04/27/2004
    Description:Child and Teen -830 Denials
    Alert:A system error has caused electronic claims submitted with code S0302 for Child and Teen Checkups for the State Public Program plans to inappropriately deny with reason code 830, Referral Code Missing or Invalid. This error impacts claims processed between 12/6/03-04/19/04. A fix has been put in place. Effective immediately, Medica can accept the electronic claim. These claims do not need to be submitted on paper. Medica will identify the claims that were inappropriately denied and reprocess the claims by 5/20/04.
    Action:No action is needed from the provider.
    Date:04/14/2004
    Description: LaborCare Anesthesia Claims- UHC System Problem Causing Some Claims to Process Incorrectly
    Alert:In March 2003, a system edit was implemented by UnitedHealthcare (UHC) to no longer take 50% reductions when the anesthesia modifiers QK (medical direction of 2, 3, or 4 concurrent anesthesiologists), QX (CRNA with medical direction by an MD), and QY (medical direction of a CRNA by an anesthesiologist) are reported by anesthesiologists contracted at a percent of billed charges. It was recently identified that anesthesia modifier reductions of 50% are being incorrectly applied to percent of charge claims that were processed on or after March 6, 2004. A system fix is scheduled for April 17, 2004. Claims processed after March 6, 2004 until the present, where percent of charge physicians were having their claims reduced by 50% when using the modifiers QK, QX, or QY, will be automatically adjusted by UHC. The estimated completion date for this adjustment project is May 15, 2004.
    Action:It is NOT necessary for the physician to submit adjustment projects.
    Date:03/23/2004
    Description: Secure Messaging Enhances Privacy Protection
    Alert:In order to comply with Health Insurance Portability and Accountability Act (HIPAA) standards, Medica will soon be using a secure-messaging tool. Medica is expecting to have this security measure implemented by the end of March. Providers will be able to safely receive secure e-mails and attachments that contain confidential, private, or personally identifiable health information (PHI) from Medica.

    In order to read secure e-mails from Medica, providers will need to register online after being prompted by an e-mail from Medica. After registering once, providers will be able to log on to Medica's secure site to retrieve e-mails and attachments that contain PHI or confidential information.

    Providers may then respond to Medica securely by e-mail. What should the external recipient do upon receipt of a secure message? 1) Recipient will receive a message in their email inbox that a secure message has been sent to them from Medica, 2) Recipient will follow instructions to register (one time) and log on to Medica’s secure site to retrieve the email.

    Medica’s Secure Messaging system is not meant to be used as a long term filing system for emails, or documents. Emails and attachments received through Medica Secure Messaging will not be available after 60 days. You should save email and/or attachments to your local computer. Providers who have questions about this may call Medica at 1-800-952-3455 and select the provider option.

    Action: No action is needed at this time.
    Updated: 06/24/2004
    Date:03/15/2004
    Description: Global Days Assignment of Add-on Codes Processing Errors
    Alert: Medica recently identified a system set-up error performed to the global days assignment of add-on codes. This caused some physician, Commercial and Government claims to deny reason code 035 (part of main procedure - service not covered). The set up error has resulted in inappropriate denials for CPT codes 90780 and 90781 regardless of other services billed with these codes. Approximately 2524 impacted claims have been identified related to the incorrect denials for codes 90780, 90781 and 90784. Appropriate system changes were made on 4/28/04 and the adjustment project for all impacted claims was completed on 6/10/04.

    In addition, evaluation and management codes were incorrectly denying reason 035 when billed with any add-on code  for  1/1/04-4/28/04 dates   of service. The impacted claims related to the incorrect denials for the add-on codes are in the process of being identified and submitted for adjustment.
    Action: No action is needed at this time.
    Date:03/15/2004
    Description: CPT Code 20610 Denying 022 or 251

    Alert: Medica recently identified an error related to the CMS policy set-up for CPT 20610.  This error caused some physician Government claims (groups 59xxx, 70xxx and 71xxx) to incorrectly deny reason code 022 (Not eligible charge, don’t bill patient) or 251 (Invalid Dx/Proc combination per NCD/LMRP).

    Claims were impacted from dates of processing 12/10/2003 - 3/15/2004.  Approximately 200 claims have been identified to be adjusted.  Target completion date to have the impacted claims adjusted by is 5/04.

    The criteria for CMS policy Intra-articular injection of Hyaluronate for treatment of osteoarthritis of the knee will continue to be applied to code 20610 submitted with J7317 or J7320 for groups 702xx or 705xx.

    Action: No action is needed at this time.
    Date: 03/03/2004
    Description: Invalid Diagnosis/Procedure Combination Per NCD/LMRP Errors (251 denial reason code)
    Alert: Medica recently identified a system set-up error which caused Commercial and Government physician and hospital claims processed on 2/26/04 to deny in error, reason 251 "Invalid Dx/Proc Combination Per NCD/LMRP."

    As previously communicated in the December 2003 Connections, the Medica Prime Solution Medicare Product follows both the National Coverage Decisions (NCDs) and Local Medical Review Policies (LMRPs).

    When submitting claims to Medica for Medica Prime Solution members (group numbers 70200-70220, 70230-70233 and 70500-70599), providers should follow Medicare Part B claims submission policies. If the Medicare Part B claims submission policy is not followed, the claim will be appropriately denied 251.

    In order to assist you in determining incorrectly denied claims as a result of this error, any 251 claim denials for groups other than noted above would be identified as an incorrectly denied claim and will be adjusted. In addition, some 251 denials for the groups listed above are incorrect due to the set up error and will be adjusted as well.

    If you'd like clarification around the appropriateness of the denial for the 70XXX groups, please review the applicable Medicare policy. If you still have questions, please contact Medica's Coding Department at Coding.Questions@Medica.com. 

    The system has been fixed, and Medica has identified 4,532 claims impacted by this issue. Impacted claims will be sent to Field Service to be adjusted. Please allow 30 days for reprocessing.

    Action: No action is needed at this time.
    Date: 02/18/2004
    Description: Central States Works to Resolve Communications Issues
    Alert: Central States Health & Welfare Fund, the administrator for TeamCare (a LaborCare group), recognizes that it has been difficult in recent months to reach any of their representatives through their phone service. They would like to advise LaborCare providers that they are addressing the issue and hope to have it adequately resolved in a timely manner. The Fund recently made changes to both its pension and its health care benefits, which resulted in a significant increase in incoming call volume. They are currently meeting face-to-face with union members around the country to discuss the changes. This should significantly cut down on the number of members needing to call in to the Fund. Central States recommends that when a provider needs to call, the best times are either early in the morning or later in the afternoon/early evening, when call volumes are lower.
    Action: Central States would like to encourage providers to use its web site, www.centralstates.org, for the easiest way to check on TeamCare enrollees' eligibility, benefits, claim status, and more. Providers will need to register prior to using this site for the first time. Also, Central States phone system has a voice response system that should be operational by the beginning of March. This IVR will allow providers who prefer to call in to receive automated assistance for issues such as eligibility and claim status.
    Date: 02/17/2004
    Description: Medicaid Claims Deny in Error - Not Eligible Charge / Don't Bill Patient
    Alert: Medica recently identified a system set-up error which caused Medicaid (59xxx groups) claims to deny in error, reason 022 "Not Eligible Charge / Don't Bill Patient." The system has been fixed, and Medica is running a report to have all claims impacted by this error adjusted appropriately. An update will be given when available on claim volume, and estimated time of project completion.
    Update: Medica has run a report and identified approximately 1,300 claims. Adjustment requests will be forwarded to Field Service today. Please allow up to 30-45 days for reprocessing.
    Action: No action is needed at this time.
    Date: 02/04/2004
    Description: Diagnosis Codes 719.71-719.79 and 719.7 Denying Inappropriately
    Alert: Medica recently identified system set-up error in the 2004 ICD-9-CM code updates. As a result of this error, claims submitted with codes 719.71-719.79 and 719.7 have been auto denying with various reason codes. The system has been corrected, and a report will be run to identify and adjust all impacted claims. The target date for completion of these adjustments is March 26, 2004. (Note: SelectCare/LaborCare claims are not impacted by this set-up error.)
    Action: If you recognize claims that were affected by this error, it is not necessary to resubmit or send an adjustment request at this time. As noted above, Medica will run a report to capture all claims impacted, and adjustments will be made accordingly.
    Date: 01/15/2004
    Description: Error causes claims to deny inappropriately as "Procedural Modifiers Required"
    Alert: Medica recently identified an error which caused participating provider claims to deny incorrectly, reason 93, "Procedural Modifiers Required." Claims affected are for dates of processing 12/6/03-1/5/04. The error has been corrected, and Medica will be running reports to capture and reprocess all claims impacted by this error.
    Action: No action required. Providers do not need to resubmit claims at this time.
    Date: 01/14/2004
    Description: UHC's self-service phone system - contacting Customer Service for LaborCare enrollee's
    Alert: Some providers may need additional assistance when using UnitedHealthcare's Voice Enable Telephone Self-Service System (VETSS) for claims, benefits, or eligibility information for those patients who access the LaborCare network, and may not be sure how to reach a customer service representative when using the automated system.
    Action: Within the Claims menu of the phone system, enter the subscriber's ID number, the patient's date of birth, the date of service, and listen for the VETSS response. Then say "Customer Service" and the call will be transferred to a customer service representative. From Benefits or Eligibility, enter the subscriber's ID number, the patient's date of birth, and wait for the VETSS response. Say "Customer Service" and the call will be transferred. As an alternative, UHC's online service can be used to access claims, eligibility, or benefits information, as well as to notify UHC of inpatient admissions. Their website is http://www.unitedhealthcareonline.com/.
    Date: 01/9/2004
    Description: UHC System Error Causing Some LaborCare Anesthesia Claims to be Processed Incorrectly
    Alert: It has been discovered that some LaborCare anesthesia claims being submitted to UnitedHealthcare (UHC) are being processed incorrectly. Due to a system error, the minutes being billed are being mis-read as units and the claims are then being paid either at too low an amount or are being returned back to the provider for additional information regarding the time.
    Action: UHC is working on a fix to the system but it has not been implemented as of yet. In the meantime, the claims processors at UHC have a workaround in place to address anesthesia claims. Providers do NOT need to submit adjustment requests, as UHC will identify claims that have been impacted by this error and will make necessary adjustments.
    Date: 12/23/2003
    Description: System error causing inappropriate denials for destruction of Actinic Keratosis
    Alert: Medica has discovered that claims submitted with CPT codes 17000 - 17004 and linked to the diagnosis 702.0, on the Part B services for our Prime Solution product (group#s 70200 - 70220 and 70500 - 70599 ), are denying off the "Removal of Benign Skin Lesions" Medicare LMRP instead of the "Actinic Keratosis" Medicare LMRP. These claims are denying incorrectly. Medica is in the process of correcting this system error. When this is completed, Medica will run a report to identify all the affected claims to be reprocessed for reimbursement.
    Action: : No action needed at this time. Providers DO NOT need to submit adjustment requests.
    Date: 12/23/2003
    Description: Hospital Claims Enhancement
    Alert: Medica has implemented an enhancement for hospital claims processing. The enhancement will require that 6 (six) header fields must match on the hospital claim before the system will automatically deny the claim as a duplicate. The header fields are as follows: Member number, Provider number, From date, Thru date, Place of Service and Admit hour.   Previously, Admit hour was not an identified header field.
    Action: : Please ensure that above criteria is met to prevent exact duplicate denials.
    Date: 12/15/2003
    Description: Medica Covers the FluMist
    Alert: Because of shortages of conventional flu vaccines, Medica is extending its coverage to include the FDA approved intranasal influenza vaccine FluMist for the 2003-2004 flu season. The hope in doing this is that the remaining supply of flu shots will get to the highest risk populations. Medica will cover nasal-spray flu immunizations under FDA approved guidelines for healthy individuals ages 5-49 . Just as it does for conventional flu shots , Medica will provide this coverage at no cost to eligible members. In addition, Medica is making its coverage of FluMist retroactive to Monday, December 8, 2003. Again, this applies to the 2003-2004 influenza season only.
    Action: : No action needed.
    Date: 12/11/2003
    Description: Co-payments on Eye exams for the MN Health Care Program
    Alert: The Minnesota Department of Human Services (DHS) has taken the position that eye exams are not considered preventive services and are subject to office visit co-payments. This varies from the typical Medica administration of co-payments for eye exams. To assure that the Medica administration of the co-payments is consistent with DHS’s administration, Medica will start to assess a copay for eye exams for its Minnesota Health Care Program enrollees starting on January 1, 2004, retroactive to dates of service October 1, 2003 and after. This decision only applies to enrollees in the group numbers ranging from 59000 to 59999.
    Action: : Co-payments will apply to the diagnosis of disorders of refraction and accommodation (ICD-9 Codes 367.00-367.99). At the present time, co-payments will not apply to code V72.0, examination of eyes and vision, as reported, because the members’ certificates of coverage specify that there is no copay for preventive annual eye exams. If you have collected co-payments from members and would like Medica to adjust your claims, contact the Provider Service Call Center for assistance. You may not need to send in individual adjustments.
    Date: 11/24/2003
    Description: Provider Administrative Forums At Medica
    Alert: The Administrative Forum scheduled for Tuesday November 25th is full. Due to the overwhelming response, we have added an additional forum to take place on Monday December 15th here at Medica's Minnetonka office. To sign up for this forum you can click on Reference Tools and Forms link on this page, go to Provider Administrative Forums, then go to "Fall - Provider Administrative Forums - Locations Sign Up Now (rev. 11/03)".
    Action: : No action required.
    Date: 11/21/2003
    Description: Enhancements on www.medica.com
    Alert: Effective 11/21/03, when you access www.medica.com, you will notice some enhancements. These enhanced services and functions found in the "Provider Services" section of www.medica.com will include the following:
    • Frequently Asked Coding Questions-Allows providers to browse and search a database of Frequently Asked Coding questions by provider network and/or topic.
    • Enhanced Search Capabilities-Allows providers more search options and quick searches (e.g. Administrative Manuals).
    • Provider Login and Registration-Required for providers to access secure content about their clinic, site or provider.
    • Provider Search Functions-Allows providers to search a provider database by product participation and specialty to obtain a provider number and clinic/site location.
    • Clinic/Site Search-Allows providers to obtain a listing of all clinics/sites associated with a Federal Tax ID to validate demographic information.
    • Enhanced Navigation-Will allow providers to locate valuable content in a more efficient way.
    Action: : Questions about use can be submitted to Medica via the feedback e-mail address (reftoolsfeedback@medica.com) located on www.medica.com in the "Provider Resources" section.
    Date: 11/21/2003
    Description: UnitedHealthcare Online Form
    Alert: The form that physicians or other health care providers use to register for "UnitedHealthcare Online" has an incorrect fax number on it. This form should be faxed to (952) 992-7015. The older version of this form had a toll-free fax number on it; that number is no longer in service. United Healthcare Online is a Web site for physicians and health care professionals to submit claims, check claim status, or verify eligibility (among other services) for those patients who have a UHC plan, such as LaborCare. Providers must register in order to use this site. If you need a registration form, contact UHC at 866-UHC-FAST (866-842-3278).
    Action: : If you are submitting this form fax form in, please send to the appropriate fax number (952) - 992-7015.
    Date: 11/17/2003
    Description: Eyewear Copays Incorrectly Assessed
    Alert: A system error was identified recently for the new MA/GAMC groups. Member group numbers affected were 59118, 59618, 59816, 59119, 59619, 59819. Due to the system error, copayments were incorrectly assessed on the eyewear supplier (i.e. Eyekraft). They should have been assessed on the dispensing fee (i.e. Optometrist). Scenario: Patient goes to Optometrist, Optometrist orders glasses from Eyekraft, Eyekraft sends glasses to Optometrist, Optometrist dispenses eyewear to patient, Optometrist bills Medica for the dispensing of the eyewear, and a copay is assessed for the dispensing of eyewear on the Optometrist's claim.
    Action: : If you are an eyewear supplier, and you have collected copayments from patients on the affected plans, you may either refund the copayment to the patient or request an adjustment from Medica. We will not automatically adjust the supplier claims to assess the copays for the supplier unless the provider makes that request. To request an adjustment you can call the Provider Service Center at 952-992-2232, or toll free at 1-800-458-5512.
    Date: 10/31/2003
    Description: iCES - A new reimbursement policy recommendation application implemented by UHG.
    Alert: A change affecting LaborCare. On October 3, 2003, UnitedHealth Group (UHG) implemented a new reimbursement policy recommendation application called INGENIX Claims Edit System (iCES). This application replaced their previous reimbursement policy application called PRS. Some minor payment differences may be noticed, but they are minimal. For additional specifics please refer to the Question & Answer (Q&A) document placed on medica.com. To locate this Q&A go to "Reference Tools & Forms" below, then scroll down to "Reference Materials".
    Action: : No action required.
    Date: 10/15/2003
    Description: Flu Shot Coupons
    Alert: Medica has sent "Flu Shot Coupons" to our members age 65 and older. These coupons are to be used for community based flu shot sites. They are not to be used for flu shots received in a participating provider's office. We want to remind you that if a member presents this coupon to you that standard billing practices should be followed. You do not need to submit this coupon to Medica.
    Action: : If you have already inadvertently submitted this coupon and have not received reimbursement please resubmit the services on a standard claim form.
    Date:  10/13/2003  
    Description:   Select Care Claims - PO Box Error for CSC in Birmingham, AL   
    Alert:  On Monday October 6 it was discovered that the Birmingham, AL post office had mistakenly identified SelectCare's repricing vendor, Computer Sciences Corporation's (CSC), post office box as being invalid due to non-payment of fees. CSC immediately produced their receipts, indicating that the fees HAD been paid. At that time, the post office re-activated the PO Box and released to CSC two days' worth of claims that had been held. However, it appears that the post office had also rejected some claims back to the senders (providers) due to their belief that the box was invalid. It is not known how many claims were sent back.   
    Action:  If you receive returned claims from CSC due to this error, please resend them to the same address as the issue is already resolved.   

    Date:  09/25/2003  
    Description:  Update: HIPAA Migration Changes for Medica's Electronic Provider Remittance Advice (EPRA) 835 Transaction  
    Alert:  Medica's conversion plans to migrate existing EPRA users to the HIPAA compliant ANSI 835 v.4010A1 have changed. Issues identified during the testing process must be corrected and retested before Medica can comfortably implement changes for this vital transaction. Because of this extended retesting process, Medica will not implement the HIPAA compliant format on October 9 as previously published. The specific date when HIPAA compliant EPRAs will be available has not yet been determined. Once an implementation date for the HIPAA compliant file is made available, Medica's Electronic Commerce staff will coordinate a conversion date to move existing users to the HIPAA compliant file format. This conversion date will be announced via a Provider Alert and email communication to EPRA receivers.  
    Action:  If you are a current Medica EPRA receiver, please inform your Practice Management System Vendor or your internal systems staff of this migration strategy change, ensuring automated posting of patient accounts is maintained. Current EPRA receivers who believe they will have difficulty with the HIPAA compliant 835 format must contact Medica Electronic Commerce at medica.electroniccommerce@medica.com or 218/733-1146 as soon as possible. For additional information, the 835 v.4010A1 Implementation Guides can be found at www.wpc-edi.com. Other questions or issues may be directed to Medica Electronic Commerce at medica.electroniccommerce@medica.com or phone (800)757-9842, option 6.  
    Date: 09/23/2003
    Description: Update: Codes A8970-58970 Set-up Error
    Alert: Update: Project run to adjust all claims affected by this error was complete on 9/8/03. Original Alert: A system error was recently identified. As a result of this error, claims submitted with codes A8970-58970 were hitting the Infertility service code and assessing a copay for non infertility claims entered between dates 4/23/03-4/24/03. The system has been corrected, and a report will be pulled and worked in order to adjust the claims affected by this error.
    Action: If you recognize claims that were affected by this error, it is NOT necessary to send an adjustment request. As noted above, a report will be pulled, and all claims will be adjusted appropriately.
    Date: 09/12/2003
    Description: Billing Changes for Newborns in Minnesota Health Care Programs
    Alert: For enrollees in Minnesota Health Care Programs, newborns will no longer be automatically enrolled into the same health plan as the mother. Effective for newborns born on or after October 1, 2003, all newborn service claims for mothers in Medica Choice CareSM — for Medical Assistance (MA) and General Assistance Medical Care (GAMC) enrollees — or Medica MinnesotaCare must be submitted to the Minnesota Department of Human Services (DHS) for payment. DHS will be responsible for payment of newborn claims for the birth month and additional months until the newborn is enrolled into a health plan.
    Action: For these reasons, Medica and DHS urge providers to use the Eligibility Verification System (EVS) to check member eligibility for MA, GAMC and MinnesotaCare. EVS is accessible by calling 651-282-5354 or toll-free 1-800-657-3613, or online by visiting the Web site http://www.mnevs.state.mn.us/.
    Date:  09/10/2003  
    Description:   Migration Date Change: Medica Electronic Provider Remittance Advice (EPRA) HIPAA Conversion  
    Alert:  Medica announces a change in scheduling for the Electronic Provider Remittance Advice (EPRA) conversion. Please be advised that the evening of October 9, 2003, Medica is scheduled to convert to the HIPAA compliant 835 v.4010A1 for Electronic Provider Remittance Advice (EPRA). Current formats or versions of the 835 will no longer be supported after this conversion date. This migration was previously scheduled for the evening of September 23. Please make a note of this scheduling change. Enrollment activity for add, changes and deletes for EPRA will be suspended from September 20, 2003 to October 9, 2003 in support of this conversion. Under a separate communication WebMD will be in direct contact with EPRA receivers regarding minor changes to the filenames delivered electronically.   
    Action:  If you are a current Medica EPRA receiver, please work with your Practice Management System Vendor or your internal systems staff to ensure a smooth transition to the HIPAA compliant 835 v.4010A1. While the changes to the HIPAA compliant 835 are minimal, accommodations may need to be made to ensure automated posting of patient accounts is maintained. For additional information, the 835 v.4010A1 Implementation Guides can be found at www.wpc-edi.com For questions pertaining to file names or file delivery, contact WebMD directly at eraimplementation@webmd.net Other questions or issues may be directed to Medica Electronic Commerce, medica.electroniccommerce@medica.com or phone (800) 757-9842, option 6.  
    Date: 09/10/2003
    Description: SelectCare Electronic Claim Submissions sent to Computer Sciences Corporation (CSC)
    Alert: In the past, the repricing vendor for SelectCare (CSC, Computer Sciences Corporation), only used one reason to electronically reject claims that were submitted electronically to CSC for processing. The one reject reason was for the group number. Recently, in August 2003, the electronic rejection reasons were expanded to include additional electronic reject reasons to help prevent these from rejecting via paper. Therefore, you will receive these rejections faster since they will be rejected electronically. The new additional electronic reject reasons are listed below: 1) invalid diagnosis codes will reject with the reason of "Primary diagnosis invalid for this carrier", 2) invalid codes and invalid modifiers will reject with the reason of "Invalid procedure for this carrier", 3) invalid date/future dates will reject with the reason of "Invalid date of service".
    Action: If you have any questions, please email Electronic Commerce at medica.electroniccommerce@medica.com.
    Date: 09/09/2003
    Description: Fall 2003 Provider Administrative Forums - Dates & Locations Finalized
    Alert: Medica's fall Provider Administrative Forum dates, and locations have been finalized. They are as follows: Monday October 27 in St. Paul, Monday November 10 in Mankato, Monday November 17 in Duluth, and Tuesday November 25 at Medica in Minnetonka.
    Action: For additional specifics, or for registration information click on "Reference Tools & Forms" below, then go to "Provider Administrative Forums".
    Date:  08/25/2003  
    Description:   Medica Electronic Provider Remittance Advise (EPRA) HIPAA Conversion  
    Alert:  Please be advised that the evening of September 23rd, 2003, Medica is scheduled to convert to the HIPAA compliant 835 v.4010A1 for EPRA. Current formats or versions of the 835 will no longer be supported after this conversion date. Enrollment activity for add, changes and deletes for EPRA will be suspended from September 5, 2003 to September 23, 2003 in support of this conversion. Under a separate communication WebMD will be in direct contact with EPRA receivers regarding minor changes to the filenames delivered electronically.  
    Action:  If you are a current Medica EPRA receiver, please work with your Practice Management System Vendor or your internal systems staff to ensure a smooth transition to the HIPAA compliant 835 v.4010A1. While the changes to the HIPAA compliant 835 are minimal, accommodation may need to be made to ensure automated posting of patient accounts is maintained. For additional information, the 835 v.4010A1 Implementation Guides can be found at www.wpc-edi.com. For questions pertaining to file names or file delivery, contact WebMD directly at eraimplementation@webmd.net. Other questions or issues may be directed to Medica Electronic Commerce, medica.electroniccommerce@medica.com or phone (800) 757-9842, option 6.  
    Date:  08/14/2003  
    Description:   Codes A7033-05508 Set-up Error - Update  
    Alert:  A system error was recently identified. As a result of this error, claims submitted with codes A7033-05508 were hitting the DME service code and assessing a copay for claims entered between dates 3/19/03-3/28/03. The system has been corrected, and a report will be pulled and worked in order to adjust the claims affected by this error. STATUS UPDATE 8/14/03 Claims affected by this system error were reprocessed on 7/24/03.   
    Action:  If you recognize claims that were affected by this error, it is NOT necessary to send an adjustment request. As noted above, a report will be pulled, and all claims will be adjusted appropriately.  
    Date: 07/24/2003
    Description: HIPAA Transaction Testing with WebMD
    Alert: WebMD, as part of its readiness planning, has testing procedures in place for the HIPAA standard transactions. All documentation about the HIPAA testing process is available on their website, www.WebMDEnvoy.com Submitters -- vendors and providers who submit claims and/or real-time transactions directly to WebMD -- interested in testing for HIPAA compliance can visit http://www.webmdenvoy.com/HIPAA/providers.html for details.
    WebMD clients who develop and maintain Claim and Real Time transaction formats begin the implementation process by completing the Implementation Survey, posted at WebMD's HIPAA Resource Center. A WebMD Implementation Specialist will contact you regarding format decisions, testing queues, and provide guidance with technical issues or questions you may have. Please review the HIPAA Implementation Flowchart, which outlines this process. Medica will be prepared and compliant by October 16th, regardless of provider's testing status. Further questions or concerns can be directed to Medica's Electronic Commerce Department, medica.electroniccommerce@medica.com or, phone 800/458-5512, option 8, extension 23460, direct dial 952/992-3460  
    Action:  If you are a direct submitter to WebMD for Claim and Real Time transactions, it is important to begin the HIPAA Implementation and Testing process by completing the Implementation Survey, if you have not already done so. Implementation Surveys can be obtained online at the WebMD HIPAA Resource Center, http://www.webmdenvoy.com/HIPAA/resource.html If you are not a Vendor or Direct Submitter to WebMD Envoy, please contact your Software Vendor, Information Systems staff or internal HIPAA personnel for details on HIPAA preparations. It is important to work closely with your vendor and WebMD to identify appropriate HIPAA solutions, monitor testing, and understand testing time frames and compliance dates. To avoid delays as the compliance date draws near, it is critical to work with WebMD and schedule testing as soon as possible.   
    Date:  07/15/2003  
    Description:   Provider Service Center Hours for Wednesday July 16th  
    Alert:  Medica will be holding all employee meetings throughout the day on Wednesday, July 16th. Our staff is encouraged to attend these meetings as it gives Medica the opportunity to provide employees with important company wide updates. Due to this, the Provider Service Center (PSC) will be open from 8:30-3:00 today. And will be closing from 3:00-5:00 We appreciate your understanding, and apologize for any inconvenience this may cause.  
    Action:  No action needed.  
    Date:  06/27/2003  
    Description:   UHC Network Transition  
    Alert:  Two issues impacting claim processing for United HealthCare enrollees accessing the LaborCare network have been identified. Issue #1: The first issue was identified earlier this year where claims were processing showing the entire charge as provider discount. Issue #2: The second issue identified concerns claims rejecting for Preferred One repricing for dates of service after the 5/1/03 transition of this membership to the LaborCare network. The issue causing this error has been identified and corrected.   
    Action:  Issue #1: No action is necessary. This issue has been corrected and claims are being adjusted to pay the correct amount. Providers should be receiving payment on these claims within the next 30 days. Issue #2: Claims may either be resubmitted or the provider may contact United HealthCare and request the claim be reprocessed.  
    Date:  06/26/2003  
    Description:   Provider Negative Payee Reduction  
    Alert:  To reduce the incidence of a provider going into negative payee, Medica will combine the Medicare and Medicaid checkwrites in July. For physician payments; Medicare currently runs a checkwrite on Tuesday and Thursday and the Medicaid checkwrite Monday and Thursday. For hospital payments; Medicare currently runs a checkwrite on Sunday and Thursday and Medicaid on Tuesday and Thursday. In July, we will combine both the Medicare and Medicaid payments to form one physician checkwrite that will run on Monday and Thursday and one hospital checkwrite that will run on Monday and Thursday.  
    Action:  No action required.  
    Date:  06/11/2003  
    Description:   Provider Administrative Forums  
    Alert:  Thank you to all who were able to attend Medica's Spring Forums. The presentation documents given at the forums are now posted on medica.com. To locate the presentations go to Reference Tools & Forms below, then go to Provider Administrative Forums.  
    Action:  No action needed.  
    Date:  05/21/2003  
    Description:   Provider Administrative Forums  
    Alert:  All Provider Administrative Forums are now full. The presentations given at the forums are now posted on medica.com.  
    Action:  To locate the presentation information click on Reference Tools & Forms below, and go to Provider Administrative Forums.  
    Date:  04/28/2003  
    Description:   Preferred One Transition  
    Alert:  United HealthCare enrollees accessing the Preferred One network will move to Medica's LaborCare network on May 1st. Claims for dates of service on, or after May 1st should be submitted to United HealthCare.   
    Action:  For more information, click on Newsletters below, then go to the April edition of Connections or Link.  
    Date:  04/03/2003  
    Description:   Provider Administrative Forums  
    Alert:  Medica's spring Provider Aministrative Forums are approaching fast. Dates and locations are as follows: May 5th in Fargo ND, May 15th in St. Paul MN, May 19th in Minnetonka MN (Medica Forum on the 19th Now Full), and May 28th in St. Cloud MN.  
    Action:  For additional specifics, or for registration information click on "Reference Tools & Forms" below, then go to "Provider Administrative Forums".  


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