January 2017
General News
Effective in March 2017:
All claims with HCPCS drug codes to require NDC, NDC units
Effective with March 2017 dates of service, Medica will expand a requirement for claims that include drug codes to also include corresponding national drug code (NDC) numbers and NDC units of measure along with the Healthcare Common Procedure Coding System (HCPCS) code. This will be expanded to all Medica claims, including those for commercial, individual and family business (IFB) and Medicare products. As part of this new requirement, Medica will reject claims with HCPCS drug codes if they lack NDC numbers and NDC units of measure.
This change will apply to both physician and facility claims for all Medica products. If providers have a claim rejected due to this new claim requirement (or claim edit), they will need to correct their claim and resubmit it so that the claim can be processed.
Medica already requires that claims for Minnesota Health Care Programs (MHCP) enrollees include the NDC number and corresponding NDC units of measure for certain HCPCS codes. Medica denies MHCP claims for lack of NDC numbers, NDC units of measure, HCPCS code units, and/or the correct modifiers.
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 "NDC, NDC units, HCPCS units needed to bill for MHCP services" article in the January 2016 edition of Medica Connections.)
Effective March 1, 2017:
IFB claims to be paid after benefit coordination with Medicare
Effective with March 1, 2017, dates of processing, Medica will implement benefit coordination with Medicare for Medicare-eligible individuals who have Medica individual and family business (IFB) plans. As a result, Medica will administer IFB claims as if these members were enrolled in Medicare and then make payments as the secondary payer. This means for Medica IFB members who are Medicare-eligible, Medica will adjudicate their claims as if Medicare had paid as primary, and then reimburse the estimated Medicare cost-sharing amount. IFB members will then be responsible for any amount not paid by Medica. This will apply to claims considered for payment under Medicare Part B coverage, so primarily professional claims.
Correction on claim impact related to investigative services
Effective with January 1, 2017, dates of service, Medica will not begin denying claims as provider liability for non-covered services considered investigative, as previously published. Medica will continue its current process, denying claims for such services as member liability whether they include a GA modifier or not.
For transparency with patients, however, Medica does recommend that providers include a GA modifier on claims for investigative services, indicating that patients have assumed liability in writing for these services. In turn, when providing investigative services, providers should clarify with patients that they accept liability for them, and document this accordingly. As a reminder, Medica commercial-group and individual and family (IFB) members can sign forms like the Medica “Pre-Service Payment Consent Form.”
(Update to “GA modifier to drive liability for investigative services” article in the October 2016 edition of Medica Connections.)
Due by February 10, 2017:
Annual ‘Disclosure of Ownership’ forms needed soon
Each year, providers must complete and submit an updated “Disclosure of Ownership Statement” in accordance with regulatory agency requirements. This year, providers should complete and return this disclosure form by February 10, 2017. It can be returned to Medica by e-mail. Providers will also receive this annual request by U.S. mail next month.
As a reminder, providers who see patients covered under Medica products for government programs need to complete and return the Disclosure of Ownership Statement to Medica annually. This step is necessary for Medica to comply with contracts it holds with both the Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Human Services (DHS).
Medica wishes to thank providers for their time and a prompt response to this obligation. More details about this compliance requirement are available in the Medica Provider Administrative Manual.
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Clinical News
Effective March 1, 2017:
Medica to make UM policy change
Medica will soon revise the following utilization management (UM) policy that requires prior authorization, effective beginning with March 1, 2017, 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.
Heart transplantation
Medica has recently reviewed its policy on heart transplants and has made a change to the medical necessity criteria: Chagas disease has been removed as a contraindication.
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 March 1, 2017; 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 March 1, 2017:
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, 2017, unless otherwise noted.
UM policies – Revised
These versions will replace all previous versions.
| Name |
Policy number |
| Genetic Testing for Susceptibility to Hereditary Breast and/or Ovarian Cancer |
III-DIA.04 |
| Heart Transplantation (Adult and Pediatric) |
III-TRA.12 |
| High Frequency Chest Wall Compressions (HFCWC) Devices |
III-DEV.20 |
| Percutaneous Tibial Nerve Stimulation |
III-MED.07 |
| Varicose Vein and Venous Insufficiency Treatments |
III-SUR.26 |
Coverage policies – Revised
These versions will replace all previous versions.
| Name |
| CT Colonography, MR Colonography, CT UGI Endoscopy (formerly Virtual Colonoscopy and Virtual Upper GI Endoscopy; effective 12/21/16; see details) |
| Enhanced External Counterpulsation (EECP) |
| Fecal/Stool DNA (sDNA) Testing for Colorectal Cancer Screening and Monitoring (effective 12/21/16; see details) |
| Repetitive Transcranial Magnetic Stimulation (rTMS) (effective 12/21/16; see details) |
| Serum Drug Levels to Monitor Tumor Necrosis Factors (TNF) Inhibitors |
| Whole Genome Sequencing (formerly Whole Exome/Genome Sequencing; administrative update) |
Coverage policies – Inactivated
| Name |
| Access Techniques for Lumbar Interbody Fusion (inactivated 11/16/16) |
ICSI guidelines – Revised
These guidelines are available on medica.com
| Name |
| Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management (updated September 2016) |
These documents will be available online or on hard copy:
Improving adherence to antidepressant medication therapy
About 21 million Americans suffer from some form of depression each year. There are 6.7 percent of adults in the United States who have major depression. However, less than one-half of these people receive treatment.
Left untreated, depression can lead to serious impairment in daily functioning as well as a change in sleep patterns, appetite, energy and self-esteem. Of the 50 percent of patients who are receiving treatment, nearly 68 percent of them are not taking their medication (i.e., not adherent to their antidepressant therapy). People with untreated or poorly controlled depression tend to be high health care utilizers, which leads to an economic burden for both the member and the health care system. Antidepressant non-adherence is a key factor that contributes to poorly controlled or uncontrolled depression.
Studies have found that rates of antidepressant adherence are significantly associated with how much information physicians give patients about the drug being prescribed. When prescribing antidepressants, it is important to educate patients on:
- how the medication works
- what the patient can expect from the medication
- a description of common side effects they may experience
Medica has nearly 100,000 members on an antidepressant, and 33,000 of them are overdue in filling their antidepressant medication. Medica's goal, which is aligned with the current Healthcare Effectiveness Data and Information Set (HEDIS) measure for antidepressant use, is to help members be adherent at least 80 percent of the time and encourage them to refill their medications when they have 4 days' worth of medication left. Some common barriers to adherence include:
- fear of medication
- lack of motivation
- cognitive, memory or functional deficits
Skills such as motivational interviewing, shared decision-making and assessing patient's readiness to change when adding antidepressant therapy to a patient's medication regimen can be used to overcome these barriers to adherence.
Medica is committed to improving the mental health of its members through increased antidepressant adherence. The Medica Antidepressant Refill Reminder Program is designed to remind members when they need to refill. Members who miss refilling their medication will receive a phone call after 10 days. The prescriber will also receive a notification.
Along with pharmacological therapy, lifestyle changes and behavioral therapy are crucial components to treating depression. Exercise, diet, and psychosocial interventions should all be considered as part of a patient's treatment plan.
Due by January 15, 2017:
Quality complaint reports required by State of Minnesota
Medica requires its Minnesota-based network providers to submit fourth-quarter 2016 quality-of-care complaint reports to Medica by January 15, 2017.
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
Medica’s transition to new pharmacy program almost complete
As a reminder, Medica has selected CVS Caremark as its new pharmacy benefit manager (PBM). At the same time, Medica is making several changes to its pharmacy program starting January 1, 2017. For example, all Medica member populations (commercial group, individual/family, Medicare and Minnesota Health Care Programs) will have new drug lists. One of the most significant coverage changes will apply for non-Medicare patients who manage diabetes, as coverage for blood glucose test strips will change for Medica members not on a Part D drug plan. Coverage for insulin products may change as well. Other changes will affect a small portion of Medica members, involving changes to drug tiers, prior authorization, step therapy, and quantity limits, as well as minor changes to Medica’s network of pharmacies.
Learn more about these changes and access resources at medica.com/ProviderRxChanges. Medica has also been offering trainings for providers who want more information. Two more trainings are coming up in January.
Medica wishes to thank providers for helping to ensure a smooth transition for Medica patients who will need to change their prescriptions. Again, most provider groups using an electronic medical record (EMR) should receive updated EMR drug list information for their Medica patients as of January 1.
(Update to “Diabetes product coverage to change with new pharmacy program” article in November 2016 edition of Medica Connections.)
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Administrative News
Provider College administrative training topic for January
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
"Pharmacy Benefit Manager Changes" (class code: PBM)
There are two additional dates for this training, which was also offered at the end of 2016. This webinar will give providers more detail around Medica’s switch to CVS Caremark as its new pharmacy benefit manager (PBM). It will include an overview of the transition timeline through January 2017 and what activities occurred during that time, such as provider and member outreach. This training will also outline pharmacy program changes such as prior authorization and billing parameters related to the new PBM, new drug lists coming on January 1, 2017, and contact information for CVS Caremark so providers can request medication exceptions and appeals, when needed. The class will also cover the resources available to make this transition as seamless and efficient as possible for providers and their Medica patients.
Class schedule
| Class code |
Topic |
Date |
Time |
Notes |
| PBM-WJ1 |
PBM Changes |
Jan. 5 |
11 am - noon |
Class code with “WJ” means offered via webinar in January |
| PBM-WJ2 |
PBM Changes |
Jan. 17 |
1-2 pm |
Class code with “WJ” means offered via webinar in January |
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.
The registration deadline is one week prior to the class date. Register online for a session above.
Effective January 1, 2017:
Medica to revise reimbursement policy
Medica will soon update the reimbursement policy indicated below, effective on or after January 1, 2017, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Multiple procedure payment reduction for diagnostic imaging
To further align with the Centers for Medicare and Medicaid Services (CMS), Medica will revise its Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging reimbursement policy.
This policy applies to codes in the National Physician Fee Schedule (NPFS) with multiple procedure indicator 4 performed in a single session as eligible for the MPPR reduction. Currently, the professional component (PC) of the second and subsequent procedures is reduced by 25 percent of the allowed amount. Effective January 1, 2017, this reduction will be changed from 25 percent to 5 percent. For more information, refer to “MLN Matters” on the CMS website.
This revised policy will be available online or on hard copy:
Effective January 1, 2017:
Medica to revise reimbursement policies
Medica will soon update the reimbursement policies indicated below, effective with January 1, 2017, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions will replace all previous versions.
| Name |
| Add-On Code (updated code list) |
| Assistant Surgeon (updated code list) |
| Bilateral Procedures (updated code list) |
| Bundled Services (updated code list) |
| Contrast and Radiopharmaceutical Materials (updated code list) |
| Co-Surgeon/Team Surgeon (updated code lists) |
| Global Days (updated code lists) |
| Injection and Infusion Services (updated code list) |
| Laboratory Services (updated code list) |
| Moderate Sedation (updated code list) |
| Multiple Procedure Reduction (updated code list) |
| Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction (updated code list) |
| Physical Medicine & Rehabilitation: PT, OT and Evaluation & Management (updated code list) |
| Preventive Medicine and Screening (updated code lists) |
| Professional and Technical Components (updated code lists) |
| Prolonged Services (updated code lists) |
| Services and Modifiers Not Reimbursable to Health Care Professionals (updated code lists) |
| Telemedicine (updated code list) |
These revised policies will be available online or on hard copy:
At the same time, Medica will update related code lists in two reference guides:
- Modifier Reference Guide
- Place of Service (POS) Code Reference Guide
Reminder:
Claim validation review to start in early 2017
Early in 2017, Medica plans to implement a new program for claim validation review for several types of claims, as previously published. This process will be administered by SCIO Health Analytics®, which strives to deliver actionable insights based on health care data. This new “payment integrity” program aims to reduce billing errors, as required by the Centers for Medicare and Medicaid Services (CMS). Initially the validation review will include claims for inpatient hospital services, home health care, skilled nursing facility (SNF) charges and durable medical equipment (DME) charges, as well as others. This new claim validation review program will apply to claims for most Medica members.
This program will review claims and compare them to original medical records from providers’ offices to validate the billing. SCIO Health Analytics will send out medical record requests to providers beginning in February 2017. If the services billed are found to not match the services provided, Medica may retroactively adjust or deny corresponding payments, offsetting any overpayments against subsequent claim payments from Medica. This claim impact may also result if providers do not respond in a timely manner or lack supporting data related to the claims submitted.
Note: All correspondence and appeals for this new claim validation review program will be handled by SCIO Health Analytics. Providers will continue to have the ability to appeal payment decisions.
Reminder:
Enhanced process for overpayment recovery now expanded
In November 2016, Medica expanded its enhanced overpayment recovery process and improvements to the provider remittance advice (PRA), as previously published. These changes are now applied more broadly, affecting claims for most Medica members. The changes should both simplify administrative processes and improve communications to providers about overpayment recovery.
Providers have 30 days to respond to overpayment notification letters by sending in either a refund check or a written inquiry. Providers who choose not to respond will have overpayment recovery claims offset against future claim payments after 45 days.
As a reminder, the enhancements result in:
- advanced notification letters for overpayment recovery requests to include claim details
- PRAs with more detail including a new “Overpayment Reduction Detail” page that indicates the amount of the original adjustments, all offsets, and the current balance
- automatic offsets of overpayments against future claim payments
- current claims being allowed to process against a negative balance
- a quicker turnaround time on claims being offset
Reminder:
Providers need to regularly update demographic data, per CMS
As previously published, Centers for Medicare and Medicaid Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them, beginning in 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.
Updates to Medica Provider Administrative Manual
To ensure that providers receive information in a timely manner, changes are often announced in Medica Connections that are not yet reflected in the Medica Provider Administrative Manual. Every effort is made to keep the manual as current as possible. The table below highlights updated information and when the updates were (or will be) posted online in the Medica Provider Administrative Manual.
| Information updated |
Location in manual |
When posted online in manual |
| Adding CVS Caremark pharmacy benefit manager (PBM) details to reflect implementation of new PBM |
"Pharmacy Services” section, under "Pharmacy Resources"; also in “Medica Points of Contact” section, under “Other Points of Contact”; also in “Product Portfolio” section (updated fact sheets) |
December 2016
(effective 1/1/17) |
For the current version, providers may view the Medica Provider Administrative Manual online.
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SelectCare/LaborCare News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (December 2016). Highlights that may be of interest to LaborCare® network providers include:
- Reminder on reporting modifiers for assistant surgeon, co-surgeon and team surgeon services
- Updates to prior authorization for spine and foot surgeries — scheduled for January 2017
- Update to prior authorization for new specialty medication Exondys-51 — scheduled for February 2017
- Update to prior authorization for DME device — scheduled for April 2017
View the December 2016 UHC provider bulletin.
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