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Claim Submission Requirements for Facilities
Introduction
Following the initial contracting and credentialing process, each participating provider is assigned a unique seven-digit provider number. The number must be included on all claims to distinguish where the services were provided.
Participating providers must submit claims on the member's behalf and work directly with Medica for reimbursement. Do not ask the member to submit claims for services rendered.
Correctly completing the UB-04 form will improve the turnaround time for payment of claims. Please reference the guidelines for completing this form, including which fields are required (if applicable) or optional.
View How to Complete UB-04 form. | View UB-04 Frequently Asked Questions.
Timely submission of all claims is necessary for prompt reimbursement. Claims that are not received within 180 days after the date of service will be denied. The participating provider is responsible for the claim and the member cannot be billed. For Coordination of Benefits (COB) claims—when Medica is the second payer—submission is considered timely if the claim is received within 18 months from the last date of service. Medica will accept late or additional charges associated with such claims if made within 60 days from receipt of the initial claim. Participating providers must also submit requests for adjustments so they are received within 180 days of the date of claim reimbursement or denial. To ensure compliance with this policy, participating providers should file claims with complete, accurate information. For claims that are submitted electronically, participating providers should review error reports promptly. Corrected claims must be submitted within 180 days from the date of denial. Read more about Medica's Timely Filing and Late Claims Policy
When two identical claims are received for the same service on the same date (for the same member), one will be denied as an “exact duplicate.”
Medica does not cover medications “dispensed” by a facility for outpatient or home use, unless it is a 24-hour supply of take-home drugs following an Emergency Room visit, outpatient visit or inpatient stay. To be eligible for coverage, a prescription must be filled by a participating pharmacy.
A fully denied claim that is eligible for reimbursement (e.g., claim denied because primary insurer’s explanation of benefits wasn’t attached) should be corrected and resubmitted as an entirely new claim.
Make sure the correct Medica member identification number is on the claim.
Original claim submissions will be returned for any of the following reasons: - Member’s Medica identification number is missing or invalid for date of service.
- Participating provider’s Medica identification number is missing or invalid.
- Referring physician’s name or Medica identification number is missing or invalid when required.
- Revenue code is missing or invalid.
- Subscriber/member is not on file.
- Liquid correction fluid is used in fields on the UB-92 form.
- Claims are handwritten.
- There is missing or invalid information in any of the required or required if applicable fields designated on the sample Send-back Form below.
Please Note: “Send-back” (returned) claims will include a request that the participating provider RESUBMIT the bill as an original claim. Medica does not input or track claims that have been returned to a provider due to improper claim information. Medica maintains no information about send-back claims in its system. Claims with invalid or missing DX or CPT/HCPCS codes will not get returned via sendback; they will get closed and an “Additional information letter” will get sent to the provider.
Questions regarding claim send-backs should be directed to the Provider Service Center at 1-800-458-5512, which can clarify the information needed to resubmit a claim for processing. View sample Send-back Form.
Adverse Health Events
Recalled or Replaced Medical Devices Policy
Each claim submitted to Medica, regardless of submission method, must include information covered in this section. Claims with invalid ICD9 or CPT/HCPCs codes will get closed and a letter will be generated. The claim will not be sent back.
If the information provided is valid, but not accurate (e.g., an active member number is used, but it does not apply to the member who received the service), the claim may be processed, but will require a subsequent adjustment. To avoid delays always provide the most accurate information available.
Verify Medica coverage information each time services are rendered by using Medica.com, WebMD Office, UHConline, or ClaimLynx, or by calling Provider Service Center at 1-800-458-5512 (option 1). Then press 1 to verify a member’s effective date of service or to obtain a member’s ID number. Press 2 for basic member benefit information, e.g., copayment and deductible.
Use the current UB-92 form with current ICD-9, CPT-4, National Revenue Code and DRG Coding, when applicable. Participating providers may submit claims to Medica by: - Paper claim: Paper claims must be submitted on the UB-92 claims form established by the American Medical Association (AMA).
- Electronically through WebMD® or vendor system. (Please check with vendors to determine if they have a direct connect with Medica.) Read more about electronic transation capabilities.
For discharges occurring on or after October 1, 2008, inpatient prospective payment systems (IPPS) hospitals are required to report the present-on-admission (POA) indicator on Medica’s Medicare product claims whenever Medica is the primary payer, which is consistent with Centers for Medicare and Medicaid Services (CMS) requirements. The general formula for determining the hospital payment for each diagnosis-related group (DRG) is the DRG relative weight multiplied by the hospital base rate. As with patient age, discharge status, principal and secondary diagnosis, and procedure codes, POA values are a factor in determining the DRG. Medicare claims that are submitted without a POA indicator will be denied with denial reason code 156 (“Invalid/Missing POA”). However, these claims may be resubmitted for processing with the appropriate POA indicator. While Medica requires POA indicators on all Medicare claims, Medica encourages hospitals to use them on all commercial and Minnesota Health Care Programs claims as well. General details on POA reporting
- The POA indicator is required for all claims involving Medicare inpatient admissions to general acute-care hospitals and should also be used for non-Medicare claims;
- The POA indicator is assigned to principal and secondary diagnoses;
- The POA indicator is not required for the external cause of injury code unless it is being reported as an “other diagnosis”;
- Exempt from this POA requirement are critical-access hospitals, long-term care hospitals, Maryland waiver hospitals, cancer hospitals, children’s inpatient facilities, inpatient rehabilitation facilities, and psychiatric hospitals;
- Valid POA codes include Y, N, U, W and 1;
- POA indicators should only be submitted along with correlating diagnosis codes.
UB-04 form instructions
On the UB-04 paper claim form, the POA indicator is the eight digit of form locator 67 for “Principal Diagnosis” and the eight digit of each of fields 67A-Q, for “Other Diagnosis.” One POA indicator is submitted per diagnosis code. For electronic claims using the 837I, the POA indicator should be submitted in segment K3 in the 2300 loop, data element K301. For these claims, “POA” is always required first, followed by a single indicator for every diagnosis reported on the claim. For more details about POA indicators, providers may refer to the CMS Web site. Go to CMS Web site.
Adverse Health Events
- Submit claims for only one member and one facility per form.
- Submit one attachment, i.e. Explanation of Medicare Benefit or primary carrier’s Explanation of Benefit statement, for only one member and one provider per form.
- Remove all staples from claims before submission.
- If submitting a paper claim, please make sure that the print is dark enough to read and that you are using standard-size font.
It is not advised that delayed claims be resubmitted without first verifying that the original claim is not in Medica’s computer system. To do a status check on a claim, check through WebMD, ClaimLynx or UHConline or call the Provider Service Center at 1-800-458-5512. To ensure prompt claim processing, please direct paper claims to the address indicated:
Medica
PO Box 30990
Salt Lake City, UT 84130
Additional claim mailing information can be found at Medica Mailing Addresses for Claims.
Coordination of Benefits (COB) provisions allow health plans to coordinate their reimbursements for services provided to a patient. Medica will coordinate reimbursement with another Medica benefit plan or a non-Medica benefit plan or health insurance policy.
Read more about Medica's Coordination of Benefits processes.
Providers should submit claims to the primary carrier first. After receiving reimbursement, submit the claims to Medica by following these steps. When Medicare is the primary payer: - Write the member’s Medica identification number and the Medica provider number legibly on each Medicare Summary Notice/Explanation of Medicare Benefits (MSN/EOMB) submitted.
- Include the MSN/EOMB with the claim form. (Reimbursement information written on the claim form cannot be accepted.)
- Submit the claim and MSN/EOMB to:
Medica Claims
PO Box 30990
Salt Lake City, UT 84130
When the member has coverage with another commercial insurance carrier: - If the Explanation of Benefits (EOB) is available, please include the EOB with the claim. Legibly write the member’s Medica identification number and the Medica provider number on each EOB submitted.
- If the EOB is not available, indicate the primary carrier’s payment in box 54 on the UB-92 form.
- Submit the claim and EOB (if available) to:
Medica Claims
PO Box 30990
Salt Lake City, UT 84130
Often, a member may be covered by two Medica policies. This is usually the result of a member and spouse having Medica coverage through different employer groups. A member may be covered as the subscriber under his or her own employer and as a dependent under the spouse’s policy. Please use the following guidelines when submitting double Medica coverage claims: - Always submit claims for the subscriber using his or her own identification number. Do not submit claims for either spouse as a dependent. Medica will coordinate benefits on the second policy.
- Submit claims for dependent children using the “Birthday Rule.” (In most cases, the plan covering the parent whose birthday falls earlier in the year pays first. In case of divorce, other rules may apply.)
- Send claims to:
Medica Claims
PO Box 30990
Salt Lake City, UT 84130
The following steps are taken to process COB claims: - If there are indications that a member has primary coverage through another carrier, an investigation is done with the member to confirm the COB. No claims are reimbursed until a response is received. Analysts will contact the other carrier to get correct insurance information before a letter is generated. Information such as effective date, group coverage and single/family coverage is gathered.
- Letters are sent to the member and provider when claims are denied for other insurer payment information.
- In instances where Medica is supplementing Medicare benefits (Medica Select Solution™ paper claims and Medica Prime Solution™), all Medicare Part A and Part B facility claims for Medica Prime Solution and Medica Select Solution require the MSN/EOMB in order for Medica to process the plan liability for the Medicare coinsurance and deductibles. If this information is not submitted with the original claim, it will be requested.
- For all other products, Medica accepts EOB or prior payment information in Box 54 on the UB-92 claim form.
Medica encourages the use of electronic transactions whenever possible. Several Electronic Data Interchange (EDI) options are available that can enable providers to submit claims and receive Provider Remittance Advice electronically. Also available are real-time transactions, such as eligibility verification, claim status and adjustment requests, referral entry and referral status. Medica’s Electronic Commerce (EC) Department will work with participating providers to implement the best options.
Read more about electronic transactions.
Medica’s Special Investigations Unit (SIU) is charged with preventing, investigating, reporting and, when appropriate, recovering money from health care fraud and abuse. The unit is made up of a team of investigators with managed care, nursing and law enforcement backgrounds.
Participating providers should notify the SIU of any situations where provider billing fraud may have occurred, or where members have engaged in fraudulent or abusive activity. Examples of the former include billing for services not rendered, or misrepresentation of claim data (such as upcoding or unbundling). Member abuse includes falsification of enrollment information, altering or fabricating claims, or prescription drug forgery.
To report suspected fraudulent or abusive activities please call the SIU department at 1-800-458-5512 (provider option 1, option 5, ext. 2-8478), during business hours. At other times, please call Medica’s Fraud Hotline at 952-992-2237 or 1-866-821-1331.
Read more about Medica's position on SIU and fraud and abuse.
A Provider Remittance Advice (PRA) is a summary of reimbursements made on all claims submitted. This statement is also called an explanation of benefits (EOB) when sent to members.
Read more about PRA.
Providers are able to obtain information, including downloadable forms, under the Claim Form section of Claims Tools and Forms. If providers have any questions about Medica's claim submission policy, they are encouraged to call the Medica Provider Service Center at 1-800-458-5512.
- Current Procedural Terminology (CPT-4) code books are updated and published annually by the American Medical Association (AMA). This book may be purchased directly from the AMA at 1-800-621-8335 or through a number of other book vendors.
- CPT Assistant is the official coding resource for CPT-4. This book may be purchased directly from the AMA at 1-800-621-8335. Call to obtain information on ordering.
- The CMS Health Care Common Procedure Coding System (HCPCS) Manual, which includes Level 2 (national HCPCS), Level 3 (local or Minnesota HCPCS) and Department of Human Services codes, is published locally. It may be obtained at Minnesota’s Bookstore, 117 University Avenue, St. Paul, Minn. The bookstore can provide additional ordering information at 651-297-3000 or 1-800-657-3757.
- International Classification of Diseases, Ninth Edition (ICD-9-CM), books are updated and published annually by the American Hospital Association (AHA). The books may be purchased directly from the AHA at 1-800-261-6246 or through a number of other book vendors.
- Coding Clinic: This bulletin is the official coding resource for ICD-9-CM. To obtain information on ordering, call 1-800-261-6246.
- DRG Guide Book can be found at most bookstores and business office supply companies, or by writing to:
Medicode, Inc.
5225 Wiley Post Way
Suite 500
Salt Lake City, UT 84116-2889
Return to Billing and Reimbursement.
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