May 2016
General News
Special transportation ‘Certification of Need’ form updated
The “Certification of Need” form for special transportation services has been updated as a fully interactive form on medica.com. The new form is easy to use and located on a secure portal, so it’s encrypted when submitted. As a reminder, health care providers, not transportation providers, should use this form to complete the certification process.
Special transportation is the non-emergency transport of a member with a physical or mental impairment. Coverage of special transportation is a limited benefit for Medica members enrolled in these Minnesota Health Care Programs:
- Medica Choice CareSM — for both Prepaid Medical Assistance Program (PMAP) and Minnesota Senior Care Plus (MSC+) enrollees
- Medica AccessAbility Solution® — for Special Needs Basic Care (SNBC) enrollees
- Medica DUAL Solution® — for Minnesota Senior Health Options (MSHO) enrollees
These members may qualify for special transportation services if:
- They are unable to use a bus, taxicab, private automobile, or other commercial carrier.
- They do not require ambulance service; service where a member may require medically necessary services before and during transport.
Learn more about special transportation and access the form.
Combatting fraud related to compounded drugs
Prevention is always the first step in defense against fraud, waste and abuse. Recently, Medica has experienced an increase in high-cost claims from compounding pharmacies, often located outside of Medica’s service area in the upper Midwest.
At the direction of a prescriber, compounding pharmacies often mix various ingredients together to produce a non-commercially available product. Popular compounded products include pain creams and ointments that may contain a multitude of various potent medications. Many include drugs that could cause central nervous system depression or cardiac effects that result in slow breathing, a low or irregular heartbeat, drowsiness or a loss of consciousness. Often, there is little to no clinical evidence supporting the use of these potentially dangerous pharmaceutical products.
These pharmacies frequently engage marketers to make cold calls to members in order to obtain their Medicare or insurance ID numbers as well as to solicit compounded creams or pills. The pharmacies then contact the member’s clinic and ask the member’s doctor to sign an order (prescription) for the product. Often these compounded products result in claims worth thousands of dollars, resulting in unnecessary and potentially fraudulent waste of health care dollars.
What can prescribers do to prevent this potential fraud?
- Verify that the medication requested is clinically appropriate and medically necessary for the member’s condition and is compatible with other medications the member may be taking.
- Check directly with the member that he or she requested the medication, and if appropriate, discuss other lower-cost, in-network and more-appropriate options with the patient.
- Notify Medica’s Special Investigation Unit at (952) 992-2900 of any suspicious prescription-authorization requests, particularly involving compounded medications.
As a reminder, the prevention of fraud and abuse is in everyone’s best interest.
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Clinical News
Effective July 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 July 1, 2016, unless otherwise noted.
As previously published, Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits. Medica will begin using the 20th edition of MCG Care Guidelines in July 2016, resulting in changes to several policies, as noted below.
UM policies — New
| Name |
Policy number |
| Electric Tumor Treatment Fields (effective 6/1/2016; see details) |
III-DEV.27 |
UM policies — Revised
| Name |
Policy number |
| Behavioral Health Services – Individual and Family Business (update to MCG 20th edition) |
III-BEH.01 |
| Genetic Testing for Susceptibility to Colorectal Cancer (CRC) Syndromes (update to MCG 20th edition) |
III-DIA.06 |
| Hip Arthroplasty/Replacement and Hip Resurfacing (update to MCG 20th edition) |
III-SUR.40 |
| Implantable Deep Brain Stimulation (update to MCG 20th edition) |
III-DEV.19 |
| Inpatient (Hospital) Level of Care (update to MCG 20th edition) |
III-INP.01 |
| Inpatient Rehabilitation Facility (Acute Rehabilitation) (update to MCG 20th edition) |
III-INP.05 |
| Long Term Acute Care Hospital (LTACH) (update to MCG 20th edition) |
III-INP.04 |
| Maternal Plasma Tests for Detection of Cell-free Fetal DNA for Analysis of Chromosomal Aneuploidies (update to MCG 20th edition) |
III-DIA.11 |
| Orthognathic Surgery (update to MCG 20th edition) |
III-SUR.32 |
| Proton Beam Radiation Therapy (update to MCG 20th edition) |
III-MED.06 |
| Skilled Nursing Facility (update to MCG 20th edition) |
III-INP.03 |
| Thoracic Sympathectomy for Primary Hyperhidrosis (update to MCG 20th edition) |
III-SUR.25 |
| Vagus Nerve Stimulation (update to MCG 20th edition) |
III-DEV.24 |
Coverage policies — Revised
These versions replace all previous versions.
| Name |
| Bioimpedence Spectroscopy Devices for Detection of Lymphedema |
| Cell Therapy for the Treatment of Cardiac Disease |
| Chemoembolization for Hepatic Tumors |
| Interferential Current Stimulation |
| Sleep Studies for Initial Diagnosis of Obstructive Sleep Disorders (formerly Sleep Studies for Initial Diagnosis of Obstructive Sleep Apnea) |
| Stem Cell Therapy for Peripheral Artery Disease |
| Transvaginal and Transurethral Radiofrequency (RF) Treatments of Stress Urinary Incontinence in Women |
Coverage policies — Inactivated
| Name |
| Sleep Studies for Initial Diagnosis of Sleep Disorders: Home Sleep Studies |
These documents will be available online or on hard copy:
The value of screening for chlamydia
The Centers for Disease Control and Prevention (CDC) reports that chlamydia is the most frequently reported bacterial sexually transmitted infection in the United States. An estimated 2.86 million infections occur annually. It is probable that 1 in 20 sexually active young women 14-24 years of age have chlamydia.
The Minnesota Department of Health reports that chlamydia is the most commonly reported communicable disease, and spreading rapidly. Adolescents (15-19 years of age) and young adults (20-24 years of age) have the highest rates and comprise the majority of the cases. Rates are also high for women and African Americans. Chlamydia is known as the “silent” infection because often there are no signs or symptoms.
Impact of this disease
Testing and treatment is important because chlamydia can lead to short- and long-term consequences, including:
- pelvic inflammatory disease (PID)
- upper genital tract inflammation, permanent damage to the fallopian tubes, uterus and surrounding tissues that can lead to infertility
- chronic pelvic pain
- reactive arthritis
- tubal factor infertility
- ectopic pregnancy or pre-term delivery
The consequences of untreated chlamydia can be spread to the newborn and result in ophthalmic neonatorum conjunctivitis and/or pneumonia. The consequences of untreated chlamydia in men include:
- urethritis
- epididymitis
- reactive arthritis
- unilateral testicular pain, tenderness and swelling
- conjunctivitis
Diagnosing and treating chlamydia
The U.S. Preventive Services Task Force (USPSTF) recommends chlamydia screening for sexually active women 24 years of age or younger and in older women who are at increased risk for the infection. The task force did not find enough information to determine the benefit or harm in testing men. The testing is simple: a vaginal swab for women or a urine specimen for both men and women.
Treatment for chlamydia is antibiotics as well as abstaining from sexual activity for 7 days after a single dose of an antibiotic or until completion of a 7-day course of antibiotics. The CDC recommends that both men and women should re-test about 3 months after a treatment for an initial infection. Medica strongly recommends testing any women who may be pregnant or any member in a high-risk population.
For more information, refer to the CDC or the USPSTF.
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Pharmacy News
Effective July 1, 2016:
Medica to make state-mandated changes to MHCP drug list
As of July 1, 2016, Medica will change the way it manages stimulant drugs for Minnesota Health Care Programs (MHCP) enrollees. These policy changes will apply to the Medica MHCP formulary and are part of a larger effort by the Minnesota Department of Human Services (DHS), fee-for-service Medicaid, and all other managed Medicaid plans in Minnesota. These changes will not apply to the Medica Medicare Part D formulary.
Changes affecting Medica members
Methamphetamine will be removed from the formulary. Any members with an existing prior authorization (PA) will continue to be able to receive the drug as a covered drug for the life of the PA. Members will be asked to switch to a different medication that is covered on the Medica List of Covered Drugs for MHCP. Members can ask their doctor for a new prescription or ask their pharmacist to call their doctor.
Quantity limits (QL) will also be added for the following drugs:
| Product |
DHS maximum allowed daily dose |
Medica QL changes (for adults 18 years of age and older) |
| Metadate CD and generics |
60 mg/day |
All strengths: 1 capsule/day |
| Metadate ER and generics |
60 mg/day |
• 10 mg: 1 tablet/day
• 20 mg: 3 tablets/day |
| Methylin and generics |
60 mg/day |
• Solution: 30 ml/day
• Chew tabs in 2.5 mg, 5 mg: 2 tablets/day
• Chew tabs in 10 mg: 6 tablets/day |
| Concerta and generics |
72 mg/day |
• 18 mg, 27 mg, 54 mg: 1 tablet/day
• 36 mg: 2 tablets/day |
| Quillichew ER and Quillivant XR |
60 mg/day |
• 20 mg, 40 mg: 1 tablet/day
• 30 mg: 2 tablets/day
• Suspension: 12 ml/day |
| Ritalin and generics |
60 mg/day |
• 5 mg, 10 mg: 2 tablets/day
• 20 mg: 3 tablets/day |
| Adderall and generics |
60 mg/day |
• 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg: 2 tablets/day
• 20 mg: 3 tablets/day |
| Adderall XR and generics |
60 mg/day |
• 5 mg, 10 mg, 15 mg: 1 capsule/day
• 20 mg, 25 mg, 30 mg: 2 capsules/day |
| Dexedrine ER and generics |
60 mg/day |
• 5 mg: 1 capsule/day
• 10 mg, 15 mg: 4 capsules/day |
| Dextrostat and generics |
60 mg/day |
• 5 mg: 3 tablets/day
• 10 mg: 6 tablets/day
• Solution: 60 ml/day |
| Focalin IR and generics |
20 mg/day |
All strengths: 2 tablets/day |
| Focalin XR |
40 mg/day |
All strengths: 1 capsule/day |
| Strattera |
100 mg/day |
60 mg: decrease existing QL to 1 capsule/day |
Medica will notify affected members at least 30 days prior to these changes above. Members whose current dose will exceed the dose limitations outlined above can ask their doctor, or have their pharmacist ask their doctor, to submit a request for a quantity exception. Providers may want to consider whether the current drug and dose are safe and appropriate for the member. Medication request forms for medical necessity will be required for quantity limit, step therapy and formulary exception overrides and can be submitted by their provider (see more on this below).
The Medica List of Covered Drugs for MHCP 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.
Medica drug formularies are available online or on paper:
Additional DHS changes
The following changes from DHS will not have any impact on Medica MHCP members:
| Product |
MHCP maximum allowed daily dose and/or other mandatory changes |
Why this change won’t have impact on Medica members |
| Vyvanse |
70 mg/day |
• No change because QL already in place
• All strengths: 1 capsule/day |
| Strattera |
100 mg/day |
No change to QL for following strengths:
• 10 mg, 18 mg, 25 mg, 40 mg: 2 capsules/day
• 80 mg, 100 mg: 1 capsule/day |
| Cylert and generics |
112.5 mg/day |
No impact because not on Medica List of Covered Drugs for MHCP |
| Provigil and generics |
250 mg/day; PA required |
No impact because not on Medica List of Covered Drugs for MHCP |
| Nuvigil and generics |
400 mg/day; PA required |
No impact because not on Medica List of Covered Drugs for MHCP |
| Benzphetamine |
Non-formulary |
No impact because, as a weight-loss drug, excluded from coverage |
| Phentermine |
Non-formulary |
No impact because, as a weight-loss drug, excluded from coverage |
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 July 1, 2016:
Upcoming changes to Medica Part D drug formularies
Medica posts changes to its Part D drug formularies on medica.com 60 days prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective July 1, 2016. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. As of May 1, 2016, view the latest Medicare Part D drug formulary changes.
Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:
Medication request forms
A medication 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:
- Download a Medica coverage determination form.
- Call MedImpact at 1-800-788-2949.
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Network News
Effective July 1, 2016:
Medica to implement commercial, PPO fee schedule updates
Effective July 1, 2016, Medica will implement standard fee schedule updates for commercial products in both its metro and regional service areas. The Medica SelectCareSM and LaborCare® standard fee schedules will be updated at the same time — i.e., for the Medica preferred provider organizations (PPOs).
These updates will result in an overall estimated increase to physician reimbursement. As always, the effect on reimbursement will vary by specialty and the mix of services provided.
Various fees for services without an assigned Centers for Medicare and Medicaid Services (CMS) relative value unit (RVU) will also be updated. Examples of these services include labs, supplies/durable medical equipment (DME), injectable drugs, and immunizations. This non-RVU update will also have an impact on physician reimbursement that will vary based on specialty and mix of services provided.
Medica will apply CMS-based RVU methodology where applicable. The CMS Medicare physician RVU file (National/Carrier) is available online at the CMS website.
Providers who have further questions may contact their Medica contract manager.
Effective July 1, 2016:
Medica to update Medicare physician fee schedule
Beginning with July 1, 2016, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will reflect the July 2016 Centers for Medicare and Medicaid Services (CMS) update applicable to reimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided. Updates for durable medical equipment (DME) and orthotics and prosthetics (O&P) will not be implemented at this time.
Details on Medicare changes to drug fees are available online from CMS.
Providers who have further questions may contact their Medica contract manager.
Effective July 1, 2016:
Medica to revise fee schedule for MHCP products
Effective with July 1, 2016, dates of service, Medica will implement a revised fee schedule for its enrollees in Minnesota Health Care Programs (MHCP), affecting the Medica Choice CareSM, Medica MinnesotaCare and Medica AccessAbility Solution® products. The revised Medica MHCP fee schedule will be based on the fee schedule used by the Minnesota Department of Human Services (DHS) to pay providers for services provided to its fee-for-service enrollees. The effect on reimbursement overall for specific clinics will vary by specialty and the mix of services provided.
Providers who have further questions may contact their Medica contract manager.
Fourth-quarter PCR checks to be mailed in April 2016
By the end of April 2016, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the fourth quarter of 2015. This represents a 100-percent return of the fourth-quarter 2015 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of October 1, 2015, through December 31, 2015, and dates paid of October 1, 2015, through March 31, 2016.
Note: Medica began processing claims with a 2 percent payment reduction in April 2013 due to federal sequestration legislation. The 2 percent sequester reduction was in addition to the standard PCR withhold amount for Medica Prime Solution claims. This 2 percent cut will not be included in PCR returns.
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Administrative News
Provider College administrative training topic for June
The Medica Provider College offers educational sessions on various administrative topics. The following class is available by webinar for all Medica network providers, at no charge.
Training class topic
"Advanced Claim Edits, Post-Payments and Pre-Payment Edits" (class code: APPE). This class translates the claim submission process into three components: advanced claim edits or “ACE” edits, which take place at the clearinghouse level; post-payments, which are audits constructed after a claim has been processed and paid; and pre-paid edits, which occur during a coding review prior to claim processing and output. Participants will learn how Medica has enhanced its overpayment detection and recovery program through the implementation of a pre- and post-pay claims editing solution. This class will help providers identify if a claim was denied due to one of these edits, what the denial means, and the appropriate process to appeal those denials. It will also go over the new ACE edit policy that Medica launched on January 1, 2016, which flags missing or potentially inaccurate claim information prior to submitting a claim. This ACE policy allows providers to correct their claim in “real time” to help them avoid receiving pre-pay and post-pay adjustments and denials.
Class schedule
| Class code |
Topic |
Date |
Time |
Notes |
| APPE-WJN |
ACE, Post-Pay, Pre-Pay |
June 16 |
1-3 pm |
Class code with “WJN” means offered via webinar in June |
For webinar trainings, login information and class materials are e-mailed close to the class date. To ensure that training materials are received prior to a class, providers should sign up as soon as possible.
The time reflected above allows for questions and group discussion. Session times may vary based on the number of participants and depth of group involvement.
Registration
The registration deadline is one week prior to the class date. To register for the session listed, providers may do either of the following:
Effective April 1, 2016:
Medica revises reimbursement policies
Medica recently updated the reimbursement policies indicated below, effective with April 1, 2016, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Add-On Code (updated code list) |
| Global Days (updated code list) |
| Injection and Infusion Services (updated code list) |
| Same Day Same Service (updated code list) |
| Services and Modifiers Not Reimbursable to Health Care Professionals (updated code list) |
These revised policies are available online or on hard copy:
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SelectCare/LaborCare News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (April 2016). Highlights that may be of interest to LaborCare® network providers include:
- Laboratory Services Policy to be revised — scheduled for second quarter 2016
- Prior authorization to be required for functional endoscopic sinus surgery procedures — scheduled for May 2016
- Multiple Procedure Payment Reduction for Diagnostic Cardiovascular and Ophthalmology Procedures Policy to be revised — delayed until June 2016
- Inpatient Consultation Policy to be revised — scheduled for July 2016
View the April 2016 UHC provider bulletin.
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