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Medica Administrative Manual Home > Health Management and Quality Improvement Care Management > Benefit Appeals

Benefit Appeals

By law, Medica must offer appeals rights to members for all previously denied services. At the request of the member or participating provider (on behalf of the member), the appeals staff conducts case review of previously denied services to ensure accurate review, and coverage of eligible services according to the member’s benefit document.

Provider appeal process

The Clinical Appeals Department handles appeals that are related to clinical issues only. Any issues regarding coding or reimbursement need to be directed to the Provider Service Center at 1-800-458-5512.

Participating providers may contact the Clinical Appeals Department directly to initiate an appeal request on behalf of a member, except for members covered under Medica’s Medicare products. Any new information about a previously denied service will assist in an accurate and appropriate benefit determination. Written requests for appeal initiation should be directed to:

Clinical Appeals Department
CP420
PO Box 9310
Minneapolis, MN 55440-9310
Fax Number 952-992-8403

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.


Predictive Model Program

In addition to initiating the appeal, a participating provider may direct members to call Medica’s Member Service Department to initiate the appeal themselves:

  • For Medica Choice, Elect and Premier, and Medica Insurance Company Choice Select (commercial products), call 952-945-8000 or 1-800-952-3455.
  • For Medica Select Solution™, Medica DUAL Solution™ and Medica Prime Solution™ (Medicare products), call 952-992-2300 or 1-800-234-8755.
  • For Medica ChoiceCare and MinnesotaCare (state public programs), call 952-992-2322 or 1-800-373-8335.

Member Service will research and explain the reason for the denial (e.g., a direct exclusion in the benefit document). If an appeal is requested, Member Service will assist the member in initiating an appeal for the service.

For more information regarding the review and complaint resolution, view the Complaint Review Process.

A Medica medical director is available to discuss denial decisions with participating providers. To contact a medical director, call Medica's Care Management department at 1-800-458-5512, provider option 1, option 4.

Because the Appeals unit is involved in arbitration and litigation cases filed in relation to some services, the Clinical Appeals Analysts may need to contact participating providers for further clarification on a variety of issues including claim reimbursements, medical record requests and provider consultations.

As stated in the Medica Participation Agreement, records or copies of records are to be released to Medica upon Medica request. Upon enrollment, each member signs a consent form that authorizes the release of medical records. Therefore, additional consent forms are not required.

If the medical records or reports are requested due to a claim reimbursement issue, Medica does not reimburse the participating provider for copies.

Date: 8/24/2019 10:20:41 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CMSWEB01