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Medica Administrative Manual Home > Policies and Procedures > Prior Authorization
To begin the prior authorization process, providers may submit prior authorization requests to Medica Care Management by:
Prior authorization does not guarantee coverage. Medica will review the prior authorization request and respond to the provider within ten business days after the date that the request was received, as long as all reasonably necessary information is provided to Medica.
Prior authorization is required for selected non-radiology services. For providers to obtain prior authorization, Medica requires that the following information be provided:
For more information on which services require participating providers to obtain prior authorization from Medica, please review the current Prior Authorization List of medical services. You may also order a printed copy of the prior authorization list by calling Medica's Provider Literature Request Line at 1-800-458-5512.
Download Prior Authorization List »
To find out if a member is eligible for a service, providers may call Medica’s Provider Service Center at 1-800-458-5512.
If the provider would like to discuss any utilization management (UM) decisions with a Medica Medical Director and/or Utilization Management staff, contact Utilization Management at (800) 292-2455. For general UM inquiries, the provider may also contact Provider Services at 1-800-458-5512 or reference the Medica Utilization Management Policies.
It is required that prior authorization be obtained before services are rendered. Beginning with January 1, 2014, dates of service, if any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. The provider will have 60 days from the date of the claim denial to appeal and supply supporting documentation required to determine medical necessity.
Access the Claim Appeal Request Form at medica.com »
Medica reserves the right to conduct a medical necessity review at the time the claim is received.
Please note: Medica retains the option to require prior authorization in situations of proven high utilization.
Providers are required to obtain prior authorization for weight loss surgery. Failure to obtain prior authorization will result in denial of claims as provider liability. Certain members need to receive services from approved providers in the Medica Centers of Excellence for Bariatric Care program to receive their highest benefit level.
Depending on the member’s current coverage, claims may be denied if the member sees a non-Centers of Excellence provider.
Benefits vary by group, and prior authorization is required. Lack of prior authorization will result in the denial of claims as provider liability.
To find an approved hospital and surgeon, review the Medica Centers of Excellence for Bariatric Care Approved Provider List. Due to the ongoing approval process for the program, this list is subject to change.
View more details on this program, including the list of approved providers »
Please note: For all Medica members, bariatric surgery requires prior authorization.
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