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Medica Administrative Manual

The administrative manual is a resource for all clinic and facility staff, including physicians and other health care providers, nurses, and all business staff. This manual ensures that you have accurate and timely information about Medica products, programs, policies and procedures.

 

 

Administrative Manual Sections

DME Additional Payment Provisions (PDF): Rental provisions, maintenance service agreement and purchase agreement

General Contracting Requirements (PDF): Additional contracting requirements for all providers

Minnesota Department of Health Certified Health Care Homes (PDF): Information for certified health care homes

Government Program Requirements: Requirements that apply to Medica's Medicare and Minnesota Health Care Program products, as well as contracts with Minnesota Department of Human Services

Interpreter Services: Information and requirements for providers of interpreter services

Reimbursement for Health Services: Contractual and reimbursement obligations

Resolution of Member Complaints: Information for complaint resolution

Qualified Health Plan (QHP) Requirements: Regulatory and contractual obligations for providing health services to members of Qualified Health Plans

State-Specific Contract Requirements: Requirements for providers located in the following states:

Subcontracting: Process and provisions for providers who want to subcontract with Medica

Subrogation and Recovery: Information on recovery of expenses from third parties

Telemedicine: Information on telemedicine, requirements for coverage and provider assurance statement

Adjustment Guidelines: Adjustments, refunds and adjustment time frames

Administrative Referrals: Definitions, guidelines, request process and requirements

Genetic Counselors: Administrative and billing requirements for genetic counselors

Medical-related Dental Services: Explanation of prior authorization requirements, covered services and exclusions

Medical Record Requests: Explanation of requirements when Medica requests medical records from a provider

Notification Requirements: Requirements and exclusions for inpatient services

Personal Care Assistance (PCA): Administrative and billing requirements for agencies that provide PCA services

Prior Authorization: Request process, requirements and utilization management, including weight loss surgery

Provider Quality and Efficiency Data: Information about Patient Choice, Medica Premium Designation and Minnesota Provider Peer Grouping requirements

Special Transportation: Certification requirements

Timely Filing (PDF): Submissions, resubmissions, adjustments, exceptions and late claim appeals

Claim Analysis and Recovery: Access to analysis processes and recovery tools and forms.

Claim Submission Requirements for Facilities: How to submit claims, interpret Medica's response and request adjustments.

Claim Submission Requirements for Professional Services: How to submit claims, interpret Medica's response and request adjustments.

Coding Resources: Access to code updates, guidelines and frequently asked questions.

Commercial Fee Schedule Update Policy and Commercial Fee Schedule Release Policy: Guidelines for commercial fee schedule implementation at Medica.

Coordination of Benefits (COB): How to handle COB claims and calculations, including Medicare claims.

Electronic Transactions: Access a variety of information and tools for real-time transactions, such as eligibility, claim status, referrals, provider number inquiry and electronic provider remittance advice (EPRA).

Interim Rate Changes from CMS: How to notify Medica of a CMS interim rate change.

Provider Remittance Advice: A summary of reimbursements made on submitted claims.

Reimbursement Policies: Provides payment methodology for medical and surgical services and supplies.

Claim Analysis and Recovery: Access to analysis processes and recovery tools and forms.

Claim Submission Requirements for Facilities: How to submit claims, interpret Medica's response and request adjustments.

Claim Submission Requirements for Professional Services: How to submit claims, interpret Medica's response and request adjustments.

Coding Resources: Access to code updates, guidelines and frequently asked questions.

Commercial Fee Schedule Update Policy and Commercial Fee Schedule Release Policy: Guidelines for commercial fee schedule implementation at Medica.

Coordination of Benefits (COB): How to handle COB claims and calculations, including Medicare claims.

Electronic Transactions: Log in to view eligibility, referrals, provider number inquiry and electronic provider remittance advice (EPRA). A variety of information and tools are available for real-time transactions, such as eligibility and claim status.

Interim Rate Changes from CMS: How to notify Medica of a CMS interim rate change.

Payment Integrity Program: This program focuses on ensuring that claims are paid accurately.

Provider Remittance Advice: A summary of reimbursements made on submitted claims.

Medica's position on and investigation of fraud and abuse, Medica's Special Investigations Unit (SIU), financial and health record-keeping requirements and CMS Fraud, Waste and Abuse Compliance Training requirements.

View Fraud and Abuse

Appointment Access and Office Wait Time: Acceptable time standards for patients making appointments and for wait times in the office.

Care Management: Information on the Health Pregnancy, Pediatric Case Managment, Transplant Case Management, Adult Case Management, Restricted Recipient and Medicare/Medicaid Specific Programs and Benefit Appeals.

Centers of Excellence: Information on this program and access to a list of approved providers. Includes bariatric care and organ transplant programs. 

Clinic Site Survey: Procedures for conducting a practitioner office site-related complaint survey.

Medical Policies: Find current versions of Medica utilization management (UM) policies, coverage policies, drug management policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines.

Member Rights and Responsibilities: Outlines Medica members' legal rights and responsibilities.

Medical Record Review: Examination and improvement of medical practice performance.

Quality Guidelines and Improvement: Encompasses a wide range of clinical and service quality initiatives.

Quality and Cost Transparency: We offer our members various programs and tools to explore cost and quality information to help them shop for care.

Reporting Obligations: Find information and forms intended for Medica network providers to use in responding to reporting obligations required by law, contract or accreditation standards (including those required by the National Committee for Quality Assurance, or NCQA®).

Resources to help you provide better care to your patients.

View Member Care

Our network management team is available to:

  • Negotiate a provider contract
  • Provide education, including a high-level product overview and information regarding available resources
  • Respond to questions related to provider reimbursement (i.e. contracted rates and fee schedules)

Credentialing: Complete credentialing information.

Demographic Change: Submit demographic change requests.

Join the Medica Provider Network:  Detailed information on how to become contracted with Medica.

Mental Health/Substance Abuse Services: Working with United Behavioral Health to provide Behavioral Health/Substance Abuse services.

Network Management Overview: Network development, providing contracting coordination and competitive financial arrangements.

Pharmacy policies and procedures, pharmacy related announcements and the drug lists.

View Pharmacy Services

Benefit information and overviews for each of our products, including ID card information and network restrictions.

View Product Portfolio 

Medica's general and payment protocols for contracted providers.

View Protocols

Clinic Notification to Member of Practitioner or Clinic Termination: Requirements for notifying a practitioner or clinic of termination.

Complaint Review Process: Overview of state and federal laws governing HMOs and insurance companies, including Medica's member complaint resolution process.

Continuity of Care: Requirements for notifying Medica of members' continuity-of-care needs.

Medical Records: Guidelines for documentation in members' medical records.

Participation in Reviews and Audits: Information about Medica’s quality improvement activities and studies.

Termination of Health Services by a Provider: Procedures for notifying Medica of intention to discontinue health services to the member.

Advance Directives: Information on the impact on health care providers and Medica.

HIPAA Business Associate Requirements for Providers: Detailed information for the Privacy Rule from the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Minors’ Consent to Treatment and Right to Privacy: Member confidentiality and how it is handled with minors.

Provider Privacy Policy: Information around HIPAA and other privacy practices.

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