Medica Administrative Manual > Billing and Reimbursement > Claim Submission Requirements for Facilities
Claim Submission Requirements for Facilities
Introduction
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 “How to Complete the UB-04” guidelines found under Claim Forms on the Claim Tools page for completing this form, including which fields are required (if applicable) or optional.
Timely submission of all claims is necessary for prompt reimbursement. Please refer to the below policy for claim submission, resubmission, adjustment, exception and late claim appeal requirements.
Timely Filing and Late Claims Policy (PDF)
To help avoid unnecessary claim processing denials, please review the appropriate coverage, utilization management and reimbursement policies that apply to your claim.
Medica Policies and Guidelines
Common examples of denials include, but are not limited to:
• 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."
• Claims billed with invalid or missing DX or CPT/HCPCS codes.
• A new claim is submitted with information attached for a claim that is already on file.
• Appropriate modifier was not billed for the service rendered.
• Coverage or utilization management guidelines were not met for the services billed.
• Claim not billed in accordance with current standard coding practices.
Questions regarding claim denials and issues should be directed to the Provider Service Center at 1 (800) 458-5512.
Common reasons why original claim submissions will be returned include, but are not limited to:
• Member’s Medica identification number is missing or invalid for date of service.
• Participating provider’s National Provider Identifier (NPI) is missing or invalid.
• Referring physician’s name or NPI is missing or invalid when required.
• Subscriber/member is not valid.
• Demographic information on claim does not match what Medica has on file.
• There is missing or invalid information in any of the required 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.
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.
Submission Information
Each claim submitted to Medica, regardless of submission method, must include information covered in this section. Claims with invalid ICD or CPT/HCPCS codes will be closed and a PRA or 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, Availity Office or by calling Provider Service Center at 1 (800) 458-5512.
For Minnesota Health Care Programs (MHCP), there are additional claim submission requirements that must be followed from the Minnesota Department of Human Services (DHS). Failure to submit claims in accordance with Minnesota DHS requirements may result in claim denial as provider liability.
Use the current UB-04 form with current ICD-10, CPT/HCPCS, 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-04 claims form established by the American Medical Association (AMA).
• Electronically through your clearinghouse or vendor system. (Please check with vendors to determine if they have a direct connection with Medica payer IDs.)
• 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.
• For paper claims, submit an original UB-04 or CMS-1500 form, and not a facsimile copy. Additionally, remove all staples, ensure print is dark enough to read and that you are using standard-size font.
Submit replacement and void transactions only after an organization determination is made on the original claim. Medica will replace or void the claim requested only if an organization determination has previously been made to the claim being replaced or voided. To see the status of a claim, review your remittance advice or log in to the Medica provider portal or call the Provider Service Center at 1 (800) 458-5512.
To ensure prompt claim processing, please mail paper claims to the applicable address found here.
Medica requires Present on Admission (POA) indicators on all inpatient hospital claims, with the exception of hospitals that are exempt from POA reporting per CMS. Non-exempt inpatient hospital claims that are submitted without a POA indicator may be denied. However, these claims may be resubmitted for processing with the appropriate POA indicator. This policy applies to all Medica commercial, Individual and Family Business (IFB), and government products.
General Reporting Requirements
- The POA indicator is required for all claims involving inpatient admissions to general acute-care hospitals.
- 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”.
- Per CMS, the following hospitals are exempt from the POA requirement: critical-access hospitals, long-term care hospitals, Maryland waiver hospitals, cancer hospitals, children’s inpatient facilities, rural health clinics, federally qualified health centers, religious non-medical health care institutions, inpatient psychiatric hospitals, inpatient rehabilitation facilities, Veterans administration and defense hospitals.
- Valid POA indicators include Y, W, N and U.
- 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 eighth digit of form locator 67 for “Principal Diagnosis” and the eighth 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 website.
Medica will allow interim billing for inpatient hospitalizations spanning greater than 30 days.
Interim Billing Requirements
- Claims are to be billed in at least 30-day intervals or upon discharge.
- Each claim (first, continuing, and last) must include a comprehensive list of all diagnoses and procedures — even if included on the previous claim.
- Interim bills must be submitted in the same sequence in which the services were provided using the correct type of bill sequence (0112, 0113, 0114).
- Admission date is to be reported on each claim (first, continuing, and last) and will be the same on each claim.
- The Statement Covers Period (From-Through) will vary and reflects only the dates of services performed during the respective billing period. Interim bills are not to include charges billed on an earlier claim since the "From" date on the bill must be the day after the "Thru" date on the earlier bill.
Facility Claim Data
The following facility claim (UB-04) data elements are necessary to correctly bill interim claims:
Type of Bill (FL 04):
- 0112 Interim — First Claim: Used for the first of a series of bills for the same confinement or course of treatment.
- 0113 Interim — Continuing Claim: Used when a bill for the same confinement or course of treatment has previously been submitted and it is expected that further bills will be submitted.
- 0114 Interim — Last Claim: Used to indicate the last of a series of bills for the same confinement or course of treatment.
Statement Covers Period ("From" and "Through" Dates) (FL06): The beginning and ending service dates of the period included on this bill.
Patient Status Codes (FL17): Initial and continuing interim claims must be submitted with a patient status code of 30 (still patient). Final or last claims should be submitted with the applicable patient status code indicating the disposition of the patient, i.e. transfer, discharge, death.
Medicare Advantage Prospective Payment System (PPS) Claims:
Consistent with CMS, Medica will allow the submission of interim bills in at least 60-day intervals. Subsequent interim bills must be in the adjustment bill format and must include all applicable diagnoses and procedures.
The following facility claim (UB-04) data elements should be used to correctly bill interim claims:
- For the first interim claim use bill type 112 (interim bill — first claim) with a patient status code of 30 (still patient).
- For subsequent interim bills use bill type 117 with a patient status of 30 (still patient).
- For subsequent discharge bills use bill type 117 with a patient status other than 30.
Medica requires the submission of both a revenue code and a CPT or HCPCS code on outpatient hospital claims. All revenue codes listed below must therefore be submitted with a CPT or HCPCS code, when an appropriate CPT or HCPCS code for the service(s) provided exists. Absence of the required CPT or HCPCS code may result in a claim denial.
Outpatient Hospital Revenue Code List (PDF)
This policy applies to all Medica commercial, Individual and Family Business (IFB), and government products.
Reimbursement for Skilled Nursing Facilities and Home Health Agencies
In order to be paid for Medicare-funded services, Medica network skilled nursing facilities (SNFs) and home health agencies need two components when submitting claims:
• Billed Revenue Code according to Provider Agreement for reimbursement
• Health Insurance Prospective Payment System (HIPPS) code on a second line for encounter information as required by the Centers for Medicare and Medicaid Services (CMS)
For Medicaid-funded services, the Home Health or Home Care Nurse (HCN) Care Plan is required for all home health care services the member requires.
If the home health care service is covered by Medicare, you must follow Medicare guidelines. This includes members covered under a Medicare home health plan of care and on Medical Assistance.
• Medicare requires consolidated billing of all home health care services when a member is eligible and under a home health plan of care.
For Minnesota nursing facilities, the Minnesota Department of Human Services (DHS) uses a case mix system and is based on the federally required minimum data set (MDS).
• RUGS-III is used to create Minnesota case mix classifications to help determine the per diem rates.
For more information, please refer to your provider agreement and CMS and DHS websites.
Additional Resources
Providers are able to obtain information, including downloadable forms, under the Claim Form section of Claims Tools. 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.
REV 4/2024