Medica Payment Integrity

Medica Payment Integrity focuses on ensuring claims are paid accurately. Claim controls focus on optimization of claim payment efficiencies; including payment accuracy and shared liability for all business segments and claim platforms. Payment Integrity will request refunds on claims when overpayments are identified.

Reasons for overpayments include, but are not limited to:

Duplicate payments
Fraud, Waste and Abuse (FWA) detection
Medical coding review
Reimbursement policies
Industry standard practices

Medica or its designee may request medical documentation and/or full bill itemization to substantiate the treatment items, services, and supplies provided and billed by Health Care providers, in the course of conducting reviews and audits. Resources utilized include, but are not limited to, the following:

Medica’s policies
Centers for Medicare & Medicaid Services (CMS) guidelines as stated in manuals, transmittals, articles, etc.
CMS National Coverage Determinations (NCD) and Local Coverage Determinations (LCD)
Statues and Regulations
American Medical Association Current Procedure Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) rules
Industry-standard utilization management criteria and/or care guidelines, such as MCG guidelines
National Uniform Billing Committee guidelines
International Classification of Diseases (ICD) codes
Food and Drug Administration

Medical Records Review

Medica, or its designee, has the right to request and review records related to services rendered to its members. Medica may request records and/or other billing documents to conduct reviews.

In the event Medica requests medical records from a participating provider, such provider must honor the request within 30 calendar days (unless the request is otherwise stated or separately defined within contractual language).

Under no circumstances will Medica reimburse participating providers for the cost of collecting, copying or delivering requested medical records, except when required by law or separately defined within contractual language. Participating providers, and any subcontractors or third parties who may collect, copy and/or deliver records for such providers, may not bill Medica or any Medica member for expenses related to a records request from Medica unless otherwise stated in the contractual language.

Medical Records Request Example (PDF)

Pre-Payment Medical Record Review

Medica, or its designee, conducts pre-payment reviews related to the services billed to its members and facilitates accurate claims payments.

The Treatment, Payment and Health Care Operations (TPO) exception under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR 164.506) allows the release of medical records containing protected health information between covered entities without additional authorization for the payment of health care claims. All billed charges must be supported by the clinical documentation to support the diagnosis and services/supplies that are billed.

Medica will review records to determine if the services billed are substantiated by the submitted clinical and medical documentation. If the findings do not support the services billed, Medica will process the claim accordingly. If there is a dispute of the findings, there is an opportunity to appeal.

If the requested records are not returned in the timeframe requested, the claim(s) will result in a technical denial.

Post-Payment Medical Record Review

Medica's Payment Integrity team will review claims and claims data on a post-payment basis to detect, prevent and mitigate fraud, waste, abuse and error.

The TPO exception under the HIPAA Privacy Rule (45 CFR 164.506) allows the release of medical records containing protected health information between covered entities without additional authorization for the payment of health care claims. All billed charges must be supported by the clinical documentation to support the diagnosis and services/supplies that are billed.

For purposes of fraud, waste and abuse, Medica may conduct reviews within 36 months of the original paid date counted from the time the review is initiated (or else otherwise designated by state or federal statute).

Health care professionals are asked to send complete copies of medical records within 30 days of receipt of the request (unless otherwise designated). If the requested records are not returned in the timeframe requested, the claim(s) will result in a technical denial and validated overpayment.

If an overpayment is identified, the health care professional will be notified of the findings via an overpayment letter with an explanation of findings. If there is a dispute of the findings, there is an opportunity to appeal. The health care professional will have 30 days to submit an appeal or the overpayment.

Appeals Process

Medica offers health care providers up to 2 opportunities to appeal medical record review findings. Reviews are conducted by licensed or certified staff different from the individual(s) who performed the initial review.

Appeal results will be returned with the following results:

Appeal Overturned — additional documentation reviewed indicates the claim should be paid.
Appeal Upheld — additional documentation reviewed does not change the original determination made on the claim.
Appeal Partially Overturned — additional documentation reviewed does support a portion of the original determination to be overturned on the claim; the remainder of the denied claim remains denied.

To ensure proper routing and timely review, include a copy of the findings letter and all documentation related to the appeal. Documentation should be in addition to any records previously submitted. In order to avoid offset or recovery efforts, a first-level appeal must be submitted within 30 days of the letter receipt.

Level One Appeal

A level one appeal will be reviewed by the appropriate staff i.e. Certified Coder, Registered Nurse, MD Physician, etc. Staff member(s) are different from the individuals who performed the initial review. An appeal determination will be provided within 30 days of Medica's receipt along with an explanation of the appeal upheld (including the overpayment amount) or appeal overturned rationale.

Level Two Appeal

A level two appeal must be received within 30 days of receipt of the level one appeal response letter. Level two reviews will be performed by the appropriate staff i.e. Certified Coder, Registered Nurse, MD Physician, etc. Staff member(s) are different from the individuals who performed the initial or first level review. A review at a Medical Director level may be requested in writing.

All disputes must be submitted within the outlined timeframes or as otherwise required by applicable federal or state law. If a written request is not submitted within these timeframes, the original review findings will be final.

Technical Denial

A denial of the entire claim amount will occur when services cannot be substantiated due to the health care provider's non-response to Medica's request for records.

Initial Request — An initial request for medical records will be made with a due date listed in the letter. The due date is 30 days from the date the letter was sent by Medica.
Second Request — If records are not received by the initial due date, a second request for records will be sent, allowing an additional 14 days for records submission.
Request for Overpayment Refund — If the records are not received after the second request due date, a technical denial letter will be sent with an overpayment request. The health care provider will have 45 days from the date on the refund letter to submit a refund check before the paid amount of the claims are set to offset future funds owed.

Medical Records Submissions

Health care providers receiving a request for medical records may send documentation via the following options:

Mail the records to:
Medica
Attention: Payment Integrity
MR CW230
PO BOX 9310
Minneapolis, MN 55440-9310
Fax the records to: 952-992-2401

To ensure proper routing and timely review, please include the original records request letter from Medica.

REV 9/2022