January 2016
General News
Effective January 1, 2016:
Medica to manage behavioral health for IFB members in-house
Effective January 1, 2016, behavioral health services for Medica individual and family business (IFB) members will be managed by Medica Health Management instead of United Behavioral Health (UBH). UBH will continue to manage the Medica Behavioral Health network for all other Medica members.
Medica will expand its use of MCG Care Guidelines® and follow these guidelines for behavioral health services. Evidence-based care guidelines from MCG help providers and health plans drive effective care in their own work and through the conversations that connect them. MCG provides fast access to globally sourced, clinically validated best practices that support confident clinical decision-making.
This upcoming change will apply to all IFB products sold by Medica in Minnesota, North Dakota, Iowa, Nebraska and Wisconsin. These members can be identified by group or policy “IFB” on their ID card. Here’s a sample IFB member ID card showing where the group or policy number is located:
Medica will implement a new utilization management (UM) policy outlining requirements related to this change. This new behavioral health policy will be posted soon.
Effective January 1, 2016, providers should be aware of the following changes in contact information for IFB:
- Utilization management and case management: Contact IFB Health Management:
- By phone at 1 (855) 857-2046
- By fax at (952) 992-2836
- By e-mail at [email protected]
- By U.S. Mail at Medica, Utilization Management and Clinical Appeals department, CP440, PO Box 9310, Minneapolis, MN 55440
The following are reminders and are not changing for IFB:
- Eligibility and benefits: Continue to contact the Medica Provider Service Center at 1 (800) 458-5512 for patient-specific eligibility and benefits information.
- Clinical notification: Clinical notification continues to be required for:
- Inpatient mental health, inpatient substance abuse or detoxification
- Mental health partial treatment
- Mental health or substance abuse residential treatment
- Substance abuse intensive outpatient with lodging
- Intensive outpatient therapy for treatment of autism (this also requires prior authorization)
- Claim submission: Continue to submit IFB behavioral health claims in the following manner: By mail:
Medica
P.O. Box 981647
El Paso, TX 79998-1647
Using Medica’s electronic payer ID: 12422
Effective January 1, 2016:
HIPAA referral codes needed to bill for C&TC services
States are required to follow up on referrals made as a result of a Child and Teen Checkups (C&TC) screening, provided to children and teens enrolled in Medical Assistance (MA) or MinnesotaCare, to assure that children and families receive the necessary services to correct or improve health problems. Consequently, it is important that providers report all referrals on C&TC claims using one of four required referral codes.
Effective beginning with January 1, 2016, dates of service, Medica will deny the claim line if Healthcare Common Procedure Coding System (HCPCS) code S0302 is reported on the claim without a referral condition code compliant with the Health Insurance Portability and Accountability Act (HIPAA). The denial code that will be used is 0830 (“Referral code missing, child/teen checkup”) or remittance advice remark code (RARC) M62 (“Missing/incomplete/invalid treatment authorization code”).
Child and Teen Checkups is the name for Minnesota’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. C&TC is a comprehensive child-health program provided to children and teens, from newborn through the age of 20, who are enrolled in MA or MinnesotaCare. The purpose of the program is to reduce the impact of childhood health problems by identifying, diagnosing, and treating health problems early, and encouraging the development of good health habits.
In addition, the Centers for Medicare and Medicaid Services (CMS) set a goal for states to have an 80 percent participation rate in C&TC screening services. Federal law requires that states maintain this threshold for C&TC screenings as well. This participation rate is based on eligible children receiving a C&TC screening service during the reporting year. As Minnesota works toward reaching the 80 percent participation rate, accurate billing and coding are critical in documenting the screenings that have been provided.
For more information on C&TC screening services, see the Provider Manual from the Minnesota Department of Human Services (DHS).
Effective January 1, 2016:
NDC, NDC units, HCPCS units needed to bill for MHCP services
As a clarification, and consistent with a requirement by the Minnesota Department of Human Services (DHS), Medica requires that claims for Minnesota Health Care Programs (MHCP) enrollees include the national drug code (NDC) number and corresponding NDC units of measure for certain Healthcare Common Procedure Coding System (HCPCS) codes. See the DHS list of codes for which NDC reporting is required.
Effective beginning with January 1, 2016, dates of service, Medica will deny claims for lack of NDC numbers, NDC units of measure, HCPCS code units, and/or the correct modifiers.
This MHCP requirement applies for physician-dispensed drugs billed on both institutional and professional claims. It affects the following Medica MHCP products: Medica Choice CareSM, Medica MinnesotaCare, Medica AccessAbility Solution® and Medica DUAL Solution®.
For more details on billing with NDC and HCPCS units, see “Reporting requirements for drug codes” in the February 2015 edition of Medica Connections.
Both NDC numbers and NDC units of measure are required on managed care claims unless the pay-to provider is a participant in the 340B Drug Pricing Program or is a 340B pharmacy. Providers not participating in the 340B program need to submit applicable HCPCS code units and NDC numbers and NDC units of measure on claims, as appropriate. Providers that are participating in the 340B program need to submit claims using the UD modifier with the applicable HCPCS codes, while the NDC field may be left blank. Otherwise, claims will not be processed correctly.
(Update to "Non-340B providers need to submit NDC number on MHCP claims" article in the August 2013 edition of Medica Connections.)
State makes copay changes for MinnesotaCare adults for 2016
Beginning with January 1, 2016, dates of service, MinnesotaCare adults with cost-sharing responsibility will have increased copay amounts due at the point of service. There will also be additional services that require providers to assess copays. For a list of services and related copay amounts, see the 2016 MHCP Overview of Benefits grid (on page 2).
For more details about this product, see the Medica MinnesotaCare fact sheet.
Medica Foundation announces provider grant recipients
2015 behavioral health grants total $400,000
The Medica Foundation has concluded its behavioral health grant-making in 2015, awarding program grants totaling $400,000 to eight nonprofit agencies. Program grants were awarded to several provider groups and health care foundations:
- HealthEast Foundation (St. Paul) — to develop and field test culturally relevant intervention and chemical dependency assessment tools for Karen refugees from Burma
- Touchstone Mental Health (Minneapolis) — to expand the Touchstone Health and Wellness Center to improve behavioral and physical health outcomes for adults with serious mental illnesses
- Vail Place (Hopkins, Minn.) — to partner with North Memorial Health Care to develop a whole-health model offering integrated medical and behavioral health care
This cycle of grant-making focused on programs that help people with serious mental illness and addictions recover and lead productive lives in their communities. These programs develop capabilities or change processes related to the continuum of behavioral health care service interventions, accessibility and sustainability.
Details about grant recipients, funding opportunities, giving guidelines and application deadlines are available online at medicafoundation.org. Information on Medica Foundation funding priorities and grant application periods for 2016 will be available early next year.
Health Literacy Partnership develops toolkit for providers
The Minnesota Health Literacy Partnership has developed a toolkit for providers to be more aware of “health numeracy” with patients. A key aspect of health literacy, health numeracy applies to health care information involving numbers. And health-related numbers are everywhere! As with health literacy, health numeracy can have a significant impact on a patient’s decision-making, outcomes and overall health. Health literacy is increasingly recognized as a crucial component of effective patient communication that ultimately results in high-quality health care.
“The messages we convey to patients are only as good as their interpretation, so it’s up to us to remove the guesswork whenever possible,” says Alisha Ellwood Odhiambo, chair of the Minnesota Health Literacy Partnership. “It’s important to keep things clear and simple, especially when numbers are involved.”
The new health numeracy toolkit is called “Health Numeracy — Strategies for Increasing Comprehension.” It is available on the Partnership’s website under “Training Materials.”
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Clinical News
Effective November 18, 2015:
Medica makes UM policy changes
Medica recently revised the following utilization management (UM) policies that require prior authorization, effective beginning with November 18, 2015, dates of service. These changes apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Cervical spine surgeries
Medica has reviewed artificial cervical disc replacement (i.e., cervical arthroplasty) and has determined that, in addition to use at one level, cervical arthroplasty performed at two contiguous levels is now covered when used for indications approved by the U.S Food and Drug Administration (FDA). All other indications remain investigative and therefore not covered. Currently, the Mobi-C® Cervical Disc Prosthesis is the only FDA-approved device for use at two contiguous levels. Refer to the Medica UM policy “Cervical Spine Surgeries” for specific medical necessity criteria.
Lumbar spine surgeries
Medica has reviewed artificial lumbar disc replacement (i.e., lumbar arthroplasty) and has determined that lumbar arthroplasty performed at one level is now covered when used for FDA-approved indications. All other indications remain investigative and therefore not covered. Currently, the Inmotion® Lumbar Artificial Disc (formerly Charite™ Artificial Disc) and the ProDisc-L® Total Disc Replacement are the only FDA-approved devices. Refer to the Medica UM policy “Lumbar Spine Surgeries” for specific medical necessity criteria.
Artificial intervertebral disc replacement is a surgical procedure in which a diseased or damaged intervertebral disc is replaced with an artificial device in individuals with symptomatic degenerative disc disease or herniated disc. Artificial discs have been developed to replace a disc in either the lumbar spine (lower back) or cervical spine (neck). They are intended to preserve/restore vertebral alignment, maintain spinal stability and flexibility, and alleviate pain. Surgery is performed in-patient and requires general anesthesia.
Medica previously notified providers about these two benefit changes with a Provider Alert in late November 2015.
The complete text of the policies that apply to the determinations above are available online or on hard copy:
- See Medica’s UM policies; or
- Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355.
Effective December 16, 2015:
Medica implements new coverage policy
The following benefit determination was effective beginning with December 16, 2015, dates of service. This new policy applies to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Transcatheter heart valve replacement and repair procedures
Medica has implemented a new coverage policy addressing transcatheter heart valve replacement and repair procedures. This policy replaced the previous Medica utilization management policy “Transcatheter Heart Valve Replacement and Repair Procedures.” Prior authorization of services is no longer required.
In addition, the following procedures have been added as eligible for coverage:
- Transcatheter aortic valve replacement (TAVR) using an FDA-approved system (e.g., Edwards SAPIEN™, CoreValve®) in individuals with severe symptomatic native aortic valve stenosis who are at high or greater risk for open aortic valve replacement. This is in addition to previous eligibility for use in individuals who are inoperable for open surgery.
- TAVR using the CoreValve in individuals with a failed surgical bioprosthetic aortic valve replacement who are judged to be at high or greater risk for open surgery.
- Percutaneous pulmonary valve implantation (PPVI) using an FDA-approved system (e.g., Melody® system) in children and adults with right ventricular outflow tract disorders who are appropriate candidates for open surgery.
Criteria for transcatheter mitral valve leaflet repair (e.g., MitraClip®) remain unchanged. See the coverage policy for complete coverage information.
Standard valve replacement requires an open heart procedure, in which the chest is surgically opened (i.e., sternotomy) to access the heart valves. Transcatheter (or percutaneous) heart valve replacement and repair procedures are done through small openings, eliminating the need for open surgical access. Using specially designed surgical delivery catheter systems along with radiographic guidance, the existing heart valves are accessed either through an artery or directly through the chest wall. Following proper catheter placement, a collapsed replacement valve is threaded into place and is subsequently inflated. This secures the defective valve to the wall of the heart and allows the replacement valve to function effectively. Defective heart valves that can be treated with transcatheter valve replacement include the aortic, pulmonary, and mitral valves.
Although prior authorization is no longer required, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective claims denial may result if criteria are not met.
Medica previously notified providers about this benefit change with a Provider Alert in mid-December 2015.
The complete text of the policy that applies to the determination above is available online or on hard copy:
Effective January 1, 2016:
Medica to implement new coverage policy
The following benefit determination will be effective beginning with January 1, 2016, dates of service. This new policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Urine drug testing for residential substance abuse treatment
This new policy will address urine drug testing only in residential programs for monitoring substances of abuse during treatment for initial detection and ongoing monitoring of treatment compliance. Urine drug testing is eligible for coverage according to the terms of a Medica member’s plan document only when all three of these conditions are met:
- Testing is ordered by an appropriately licensed medical professional;
- Documentation in the medical record provides clinical rationale for appropriateness of drug testing, (e.g., mental/neurological and/or drug toxicity status, individualized substance use inventory performed upon admission); and
- Test methodology and frequency complies with standard medical practice as outlined in recognized professional guidelines (e.g., American Society of Addiction Medicine) for all phases of substance abuse treatment (i.e., admission, stabilization, maintenance).
Prior authorization of urine drug testing is not required. However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective claims denial may result if criteria are not met.
Although drug analysis can be performed on multiple fluid and tissue samples, urine is the most commonly used specimen. Urine drug testing is routinely used for patient monitoring in residential drug treatment programs to detect a parent drug (prescription or illicit) and/or one of its subsequent metabolites, and to determine urine drug levels. Results are used to assist in treatment planning and monitoring.
Multiple professional guidelines (e.g., American Society of Addiction Medicine) recommend that urine drug testing be individualized to test for those drugs/substances specific to an individual’s drug history. They recommend against routine use of all-inclusive urine drug testing panels designed to test for all possible drugs of abuse. In addition, they recommend that testing be performed at the lowest frequency using test methodology (presumptive or confirmatory) tailored to the individual’s phase of treatment.
Note: Residential substance abuse treatment as prescribed by a psychiatrist, psychologist or other behavioral health professional is subject to the provisions outlined in the member’s behavioral health benefit. Prior authorization of residential admission may apply. Refer to the member’s plan document for specific coverage information.
Medica previously notified providers about this benefit change with a Provider Alert in early November 2015.
The complete text of the policy that applies to the determination above will be available online or on hard copy:
Effective February 1, 2016:
Medica to implement new coverage policies
The following benefit determinations will be effective beginning with February 1, 2016, dates of service. These new policies will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Percutaneous left atrial appendage closure devices
Medica has reviewed percutaneous left atrial appendage (LAA) closure devices and has determined that this technology is investigative and therefore will not be covered.
Percutaneous LAA closure is a minimally invasive procedure of the heart that is intended to reduce the risk of stroke in a select population of patients with atrial fibrillation, who are unable to tolerate blood thinning medications. In percutaneous LAA closure, a catheter is threaded into the heart via the femoral artery near the groin or a small incision in the chest. After entering the heart, a closure device is threaded through the catheter into the LAA and expanded to trap any clots that might form, thus preventing them from entering the bloodstream and causing a stroke. Another option is to suture the LAA closed. The only device approved by the FDA for use in percutaneous LAA closure in the United States is the Watchman™ device. However, new devices and off-label use of existing devices, some of which have resulted in serious medical complications and death, are under study.
Electric tumor treatment fields
Medica has reviewed electric tumor treatment fields (e.g., Optune System) and determined that this technology will be covered for the treatment of recurrent glioblastoma after surgical and radiological therapies have failed.
The use of electric tumor treatment fields for all other indications, including the treatment of newly diagnosed glioblastoma, is considered investigative and therefore will not be covered. Reliable evidence does not permit conclusions concerning its effectiveness.
Electric tumor treatment fields is a technology that applies low-intensity alternating electric fields to the brain, and purportedly disrupts the division of cancer cells. The Optune System consists of four sets of insulated electrodes (transducer arrays) and a generator. The arrays attach to the patient’s shaved scalp and are connected to the generator by wires. The patient wears the device continuously while treatment is being delivered (20-24 hours per day), for at least four weeks, and treatment can last as long as several months. It is theorized that the application of the alternating electric fields disrupts the division of cancer cells in the brain.
The complete text of the policies that apply to the determinations above will be available online or on hard copy:
Effective February 1, 2016:
Medica to make UM policy change
Medica will soon revise the following utilization management (UM) policy that requires prior authorization, effective beginning with February 1, 2016, dates of service. This change will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Percutaneous tibial nerve stimulation
Medica has reviewed additional indications for percutaneous tibial nerve stimulation (PTNS) and has determined that all indications other than overactive bladder (OAB) are investigative and therefore will not be covered. These non-OAB indications include, but are not limited to, neurogenic bladder, fecal incontinence, constipation, chronic pelvic pain, and use in individuals less than 18 years of age.
PTNS is a minimally invasive, office-based treatment for urinary voiding dysfunction in patients who have failed behavioral and/or pharmacologic therapies. PTNS consists of a battery-powered, external pulse generator that delivers a low-voltage electrical impulse using a needle electrode placed near the ankle as an entry point. The stimulator’s impulses travel along the tibial nerve to the nerves in the spine that control pelvic floor function.
All of the medical necessity criteria for OAB remain unchanged, with the exception of an additional criterion requiring that the individual be 18 years of age or older. Refer to the Medica UM policy titled "Percutaneous Tibial Nerve Stimulation" for detailed medical necessity criteria. This policy was formerly titled "Posterior Tibial Nerve Stimulation for Overactive Bladder."
The complete text of the policy that applies to the determination above will be available online or on hard copy:
- See Medica’s UM policies as of February 1, 2016; or
- Call the Medica Provider Literature Request Line for printed copies of documents.
Effective February 1, 2016:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective February 1, 2016, unless otherwise noted.
UM policies — New
Prior authorization will be required.
| Name |
Policy number |
| Behavioral Health Services – Individual and Family Business (IFB) (effective 1/1/16) |
III-BEH.01 |
UM policies — Revised
Prior authorization is required. These versions will replace all previous versions.
| Name |
Policy number |
| Autologous Cultured Chondrocyte (Carticel®) Transplantation for the Knee |
III-SUR.35 |
| Cervical Spine Surgeries (effective 11/18/15) |
III-SUR.37 |
| Extended Hours Home Care (Skilled Nursing Services) for Patients with Medically Complex or Medically Fragile Conditions |
III-HOM.01 |
| Genetic Testing for Susceptibility to Colorectal Cancer (CRC) Syndromes (revised to reflect use of MCG Care Guidelines®) |
III-DIA.06 |
| High Frequency Chest Wall Compression (HFCWC) Devices |
III-DEV.20 |
| Home Health Aide |
III-HOM.02 |
| Humanitarian Device Exception |
III-DEV.18 |
| Lumbar Spine Surgeries (effective 11/18/15) |
III-SUR.34 |
| Orthognathic Surgery (revised to reflect use of MCG Care Guidelines) |
III-SUR.32 |
| Percutaneous Tibial Nerve Stimulation (formerly Posterior Tibial Nerve Stimulation for Overactive Bladder) |
III-MED.07 |
| Positron Emission Tomography (PET) Scan |
III-DIA.12 |
| Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome (revised to reflect use of MCG Care Guidelines) |
III-SUR.08 |
| Varicose Vein and Venous Insufficiency Treatments |
III-SUR.26 |
UM policies — Inactivated
| Name |
Policy number |
| Transcatheter Heart Valve Replacement and Repair Procedures (effective 12/16/15) |
III-SUR.36 |
Coverage policies — New
| Name |
| Electric Tumor Treatment Fields (Optune System) |
| Percutaneous Left Atrial Appendage Closure Devices |
| Transcatheter Heart Valve Replacement and Repair Procedures (effective 12/16/15) |
| Urine Drug Testing (UDT) for Residential Substance Abuse Treatment (effective 1/1/16) |
Coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Annulus Fibrosus Repair Devices (formerly Surgical Devices for Annulus Fibrosus Repair after Spinal Surgery) |
| Genetic Testing for Prostate Cancer |
Coverage policies — Inactivated
| Name |
| Artificial Intervertebral Disc Replacement (effective 11/18/15) |
| Systems Pathology Testing for Predicting Risk of Recurrent Prostate Cancer (incorporated into Genetic Testing for Prostate Cancer) |
These documents will be available online or on hard copy:
Effective March 1, 2016:
Medica to implement new coverage policies
The following benefit determinations will be effective beginning with March 1, 2016, dates of service. These new policies will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Intense pulsed-light therapy for dry eye disease
Medica has reviewed intense pulsed-light (IPL) therapy for dry eye disease and has determined that IPL therapy for this indication is investigative and therefore will not be covered.
Evaporative dry eye, one cause of chronic dry eye, results from ocular rosacea (inflammation of the eyelid skin). This causes the meibomian glands in the eyelids to fail to produce enough natural oil to reduce evaporation of tears. This may result in a burning or gritty sensation in the eye, redness, and/or blurry vision. Standard treatments for dry eye disease include, but are not limited to, artificial tear drops or ointments, medications, temporary punctal occlusion, and punctal plugs.
IPL treatment has also been suggested for this condition. IPL treatment uses brief, powerful bursts of light at specific wavelengths applied to the outside of the eyelid. Treatment is purported to raise the temperature of the skin, cause changes in blood vessels near the surface of the skin, and aide in elimination of problematic flora on the skin and eyes. The exact mode of action is unknown. Treatment is performed in the outpatient setting and may require repeated applications.
Meibomian gland evacuation therapies
Medica has reviewed meibomian gland evacuation therapies for meibomian gland dysfunction (e.g., heat and intermittent pressure therapy; meibomian gland duct probing) and has determined that these treatments for this indication are investigative and therefore will not be covered.
Meibomian gland dysfunction occurs when the glands become blocked with thickened secretions. Glands that have become chronically clogged may eventually become unable to secrete oil which results in permanent changes in the tear film layer resulting in dry eyes. Symptoms may include dryness or watering, burning or itching, redness, light sensitivity, and/or blurry vision.
One example of an office-based heat and pressure procedure for patients with meibomian gland dysfunction is the LipiFlow® Thermal Pulsation System. It is intended to provide controlled heat to the inner eyelid surface, close to the meibomian glands, and intermittent pressure to the outer eyelid to facilitate release of substances blocking drainage of the glands. The system is comprised of a console physician interface (i.e., the electrical component providing heat) and a patient activator interface (i.e., the pressure/massage component).
One example of an office-based duct probing system for patients with meibomian gland dysfunction is the Maskin Meibomian Gland Intraductal Probe. It is intended to mechanically open obstructions purported to occur at the opening and within the meibomian gland duct. Physicians apply local anesthesia and subsequently probe the obstructed ducts on the lids. If the individual does not find relief with the initial probe, larger probes are available.
The complete text of the policies that apply to the determinations above will be available online or on hard copy:
Effective March 1, 2016:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective March 1, 2016, unless otherwise noted.
Coverage policies — New
| Name |
| Intense Pulsed Light (IPL) Therapy for Dry Eye Disease |
| Meibomian Gland Evacuation Therapies |
Coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Cytochrome P450 (CYP450) Variant Genotyping (e.g., CYP2D6, CYP2C9, CYP2C19, CYP1A2, CYP3A4) (formerly Cytochrome P450 (CYP450) Genotyping) |
| Autologous Blood-Derived Products (Platelet-Rich Plasma, Autologous Conditioned Serum, Autologous Whole Blood) |
| Multichannel Intraluminal Esophageal Impedance with pH Monitoring |
These documents will be available online or on hard copy:
Medica outlines 18 key quality-of-care priorities for 2016
Medica continues each year to evaluate its key priorities with a continued emphasis on high-quality care for all Medica members. These priorities cross all lines of business: Medica commercial, individual and family business (IFB), Medicare and Minnesota Health Care Programs (MHCP). Medica’s network and membership are in the following states: Minnesota, North Dakota, South Dakota, Wisconsin, and, newly added for 2016, Iowa and Nebraska. Focusing on key quality measures helps Medica maintain accreditation with the National Committee for Quality Assurance (NCQA), meet requirements in the states where Medica operates, and continue to maintain financial stability. Medica will especially focus on quality measures that affect Medicare Star ratings. Medica strives to be a 5-star company offering Medicare plans.
See the list of 2016 priorities.
These are not only the quality-of-care issues Medica will focus on, but these 18 priorities will be measured and monitored throughout 2016.
Due by January 15, 2016:
Quality complaint reports required by State of Minnesota
Medica requires its Minnesota-based network providers to submit fourth-quarter 2015 quality-of-care complaint reports to Medica by January 15, 2016.
The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form).
Providers can now send reports by e-mail to [email protected]. Otherwise, reports can still be sent by fax to 952-992-3880 or by mail to:
Medica Quality Improvement
Mail Route CP405
PO Box 9310
Minneapolis, MN 55440-9310
Report forms are available by:
Note: Providers submitting a report for multiple clinics should list all the clinics included in the report. Providers who have questions about the complaint reporting process may:
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Pharmacy News
Effective March 1, 2016:
Medica to update commercial, Marketplace, MHCP drug lists
Medica has reviewed the following products, with their respective coverage status to be effective March 1, 2016. As indicated in the table below, these changes will apply to the Medica Commercial Preferred Drug List; the Preferred Drug List for individual and family business (IFB) members and small group plan members; and the Medica List of Preferred Drugs for Minnesota Health Care Programs (MHCP). The Medica MHCP formulary applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.
See the full list of changes.
Medica drug formularies are available online or on paper:
Medication request forms
A uniform formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
Effective March 1, 2016:
Medica to implement new pharmacy benefit drug UM policies
Medica will soon implement the following pharmacy benefit drug utilization management (UM) policies, effective with March 1, 2016, dates of service. Prior authorization will be required for the corresponding medical pharmacy drugs.
Pharmacy benefit drug UM (prior authorization) policies — New
Prior authorization will be required.
| Name |
| metformin extended-release (Fortamet® and Glumetza®) for these 2 brands only |
| famotidine and ibuprofen combination (Duexis®) |
| esomeprazole magnesium trihydrate and naproxen combination (Vimovo®) |
These new pharmacy benefit drug UM policies will be available online or on hard copy:
Effective March 1, 2016:
Medica to update pharmacy benefit drug UM policies
Medica will soon update the following utilization management (UM) policies for pharmacy benefit drugs, effective with March 1, 2016, dates of service.
Pharmacy benefit drug UM (prior authorization) policies — Revised
Prior authorization is required. These versions will replace all previous versions.
| Name |
| alfecept (Amevive®) |
| carglumic acid (Carbaglu®) |
| nabilone (Cesamet®) |
| cholic acid (Cholbam®) |
| tesamorelin (Egrifta®) |
| etanercept (Enbrel®) |
| epoetin alfa (Epogen®, Procrit®) |
| transmucosal fentanyl products |
| tasimelton (Hetlioz®) |
| adalimumab (Humira®) |
| palbociclib (Ibrance®) |
| lomitapide (Juxtapid®) and mipomersen (Kynamro®) |
| ivacaftor(Kalydeco®) |
| anakinra (Kineret®) |
| olparib (Lynparza®) |
| glycerol phenylbutyrate (Ravicti®) |
| trametinib (Mekinist®), dabrafenib (Tafinlar®), and vemurafenib (Zelboraf®) |
| ceritinib (Zykadia®) |
These updated pharmacy benefit drug UM policies will be available online or on hard copy:
Effective March 1, 2016:
Medica to add new UM policies for medical pharmacy drugs
Medica will soon implement the following new medical pharmacy drug utilization management (UM) policies, effective with March 1, 2016, dates of service. Prior authorization will be required for the corresponding medical pharmacy drugs.
Medical pharmacy drug UM (prior authorization) policies — New
Prior authorization will be required.
| Drug code |
Drug brand name |
Drug generic name |
| J9032 |
Beleodaq |
belinostat |
| J9039 |
Blincyto |
blinatumomab |
| J9308 |
Cyramza |
ramcirumab |
| J3380 |
Entyvio |
vedolizumab |
| J1575 |
Hyqvia |
immune globulin, subcutaneous |
| J9271 |
Keytruda |
pembrolizumab |
| J0202 |
Lemtrada |
alemtuzumab |
| J9299 |
Opdivo |
nivolumab |
| J0596 |
Ruconest |
C1 inhibitor, recombinant |
| J1300 |
Soliris |
eculizumab |
| J2860 |
Sylvant |
siltuximab |
These policies will apply to Medica commercial, Minnesota Health Care Programs (MHCP) and individual and family business (IFB) members, but not to Medica Medicare members. All of these policies will be subject to pre-payment claims edits as well.
The new medical pharmacy drug UM policies above will be available online or on hard copy:
Effective March 1, 2016:
Medica to add new medical pharmacy claims-edit drug policies
Medica will soon implement the following new claims-edit policies for medical pharmacy drugs, effective with March 1, 2016, dates of service.
Medical pharmacy claims-edit policies — New
| Drug code |
Drug brand name |
Drug generic name |
| J7328 |
Gel-Syn |
sodium hyaluronate |
| Q9980 |
Genvisc |
sodium hyaluronate |
These policies will apply to Medica commercial and Minnesota Health Care Programs (MHCP) members, but not to Medica Medicare or individual and family business (IFB) members.
The new medical pharmacy claims-edit drug policies above will be available online or on hard copy:
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Administrative News
Reminder:
Process for claim adjustments and appeals to change
As previously published, Medica will implement a new process for claim adjustments and appeals effective with January 1, 2016, dates of processing. This new process will limit the number of requests Medica will review after a claim has been adjudicated. The limit will include two requests: one request for a claim adjustment and one for a claim appeal, as a final request. Any additional submissions will be viewed as duplicates and denied as provider liability.
To submit a request beginning January 1, 2016, providers should complete the “Claim Adjustment or Appeal Request Form,” then attach supporting documentation and send it to Medica at the appropriate address on the form. The new Claim Adjustment or Appeal Request Form will replace the existing Claim Adjustment Request Form and the Claim Appeal Request Form. These current forms should no longer be used as of January 1.
For more details on these changes, refer to the Medica Provider Administrative Manual.
Reminder:
Advanced claim edits to reduce claim denials, speed payments
As previously published, Medica will launch a new claims-editing enhancement effective January 1, 2016, that will improve efficiency for claims processing. This new “advanced claim edits” system should result in fewer claim denials and appeals and speed up payment. It should be seamlessly integrated so that providers can use new claim edits during the normal electronic data interface (EDI) process, as electronic claims are prepared for submission.
Providers should already be talking to their EDI clearinghouse or billing service about this upcoming change, since they would already be getting 277CA claim submission reports for review. Provider staffs will be able to edit problem areas of a claim well in advance of submitting it, at no added cost, helping to improve cash flow. To accomplish this, the full 277CA claim submission reports include new “Smart Edits.” Here are two examples:
STC*A3>23>41**U*********SMARTEDIT: SMARTEDIT INFO A POTENTIAL CODING ERROR WAS IDENTIFIED WITH THIS CLAIM. PLEASE SEE STC 2220D LOOP FOR SPECIFIC INFORMATION. IF YOU WISH TO CONTINUE WITHOUT UPDATES PLEASE RESUBMIT THE CLAIM IN ITS CURRENT STATE TO BYPASS ADDITIONAL SMARTEDITING.~
STC*A3>23>41**U*********SMARTEDIT: PER CCI GUIDELINES PROCEDURE CODE 99213 HAS AN UNBUNDLE RELATIONSHIP WITH PROCEDURE CODE 90471 BILLED FOR THE SAME DATE OF SERVICE. REVIEW DOCUMENTATION TO DETERMINE IF A MODIFIER OVERRIDE IS APPROPRIATE.~ |
A list of new edits, with details for each, will be posted online soon.
By reviewing the reports, providers will be able to correct claim edits in advance. Full transaction reports will be needed to see and correct any errors on the file — These new reports should be more comprehensive than current reports that providers see from clearinghouses and billing services.
(Update to "New claim edits should speed up claim submission, payments" article in the December 2015 edition of Medica Connections.)
Medica postpones reimbursement policy implementation
Medica previously announced it would implement the new reimbursement policy “Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures,” effective with November 15, 2015, dates of service. At this time, Medica has postponed this policy implementation until further notice.
(Update to "Medica to implement new reimbursement policy" article in the October 2015 edition of Medica Connections.)
Reminder:
Providers required to regularly update demographic data
As previously published, Centers for Medicaid and Medicare Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them, effective January 1, 2016. The new rules state, among other things, that provider directories be accurate and updated regularly, in compliance with CMS guidance. As a result, providers need to update their practitioner and site-level demographic data in Medica’s directories as soon as they know of a change to that data, and to regularly review their demographic information for accuracy. See more details.
Correct diagnosis codes required for authorization requests
Providers should make sure they are entering the appropriate ICD-10 (or ICD-9) code for their dates of service when completing administrative referrals and admission notifications on medica.com. Without the correct diagnosis code, any related claims may not be processed correctly, resulting in claim delays, incorrect payment, or claim denials.
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PPO News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (November 2015). Highlights that may be of interest to LaborCare® network providers include:
- Prior authorization for infertility services — now effective
- Reporting OB procedure date spans — clarification on when to use ICD-9 vs. ICD-10 code
- Genetic counseling required for prior authorization — scheduled for January 2016
- Maximum-frequency-per-day code revision — scheduled for first quarter 2016
View the November 2015 UHC provider bulletin »
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