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Medica Administrative Manual Home > Special Contracting Requirements > Reimbursement for Health Services

Reimbursement for Health Services

Disclosure of Fee Maximums

To Get Information

After signing a confidentiality agreement, participating providers can obtain fee maximum information for up to 30 codes.

Medica fee maximums, and the method by which they are determined, are considered proprietary information. Fee maximum information will be provided by Medica with specific conditions. Fee maximum information disclosed to a participating provider cannot be disclosed to another party without prior written authorization by Medica except to Medica members pursuant to MINN. STAT. 62J. 81. As required by law, the provider may provide a good faith estimate of the specific reimbursement the provider expects to receive from Medica for the health care services the provider will provide, upon the request of the Medica member.

To request the confidentiality agreement or to obtain fee maximum information, participating providers should:

  • Contact their contract manager, or
  • Call the Provider Service Center at (800) 458-5512 (option 1, option 2).

Participating facility providers must refer to their Medica Participation Agreement for reimbursement provisions.

Disclosure to Members

Participating providers may discuss Medica’s provider reimbursement methodology with members, subject only to providers’ general contractual and ethical obligations not to make false or misleading statements.

As required by MINN. STAT. 62J.81, participating provides may also provide to Medica members a good faith estimate of the specific reimbursement they expect to receive from Medica for the specific services they will be providing when Medica members request such information.

Members may request provider reimbursement information disclosures, as required by the Patient Protection Act of 1997, from Medica’s Customer Service Department. Members can also find this information in their benefit document.


Reimbursement for Professional Services

See details on enhanced payment rates for certain primary care and vaccine administration services

Contractual Obligations

Participating providers must submit claims for health services according to Medica’s administrative requirements. These include Medica’s billing requirements for coding and claim submission.

Participating providers are contractually bound by their Medica Participation Agreement to accept as reimbursement the lesser of:

  • The clinic’s customary charge, less Provider Contingency Reserve (PCR) and any applicable copayments, coinsurance and deductibles; or
  • Medica’s established fee maximums, less PCR and any applicable copayments, coinsurance and deductibles.

Members may not be balance-billed. Members cannot be required to prepay for services.

PCR withhold does not apply to Medica Choice Care or Medica MinnesotaCare products.

In accordance with statutory requirements and the Medica Participation Agreement, providers cannot hold any Medica member responsible for reimbursement of covered health services, except for copayment, coinsurance or deductible amounts. This includes events such as breach of provider agreement or Medica’s failure to reimburse for covered health services.

When a Medica member is eligible for coverage by more than one benefit plan and Medica is the secondary carrier, reimbursement is made on the unpaid balance, up to the Medica fee maximum. The exception would be Medica’s MinnesotaCare and Choice Care members who are eligible for Medicare benefits. Per our contract with the Department of Human Services (DHS), effective with a service date of April 1, 2001, coordination of benefits includes picking up any applicable copayments, coinsurance or deductibles on behalf of the member up to the Medicare allowed amount.

Participating providers must cooperate with Medica’s coordination of benefits and subrogation efforts. Details regarding coordination of benefits are contained in the Medic Participation Agreement.

Medica will reimburse providers directly unless assignment has been made to a third party.

Medica Choice, Medica Insurance Company, Medica Premier Fully Insured or Medica Elect

Reimbursement obligations for coverage that begins or ends during an inpatient hospital stay for members with coverage under a Medica Choice, Medica Insurance Company, Medica Premier Fully Insured or Medica Elect benefit document:

  • If another plan carrier replaced Medica Choice/Insurance/Premier/Elect, Medica Choice/Insurance/Premier/Elect will reimburse eligible physician and hospital claims through the member’s discharge date from that facility.

  • In all other situations, including a change of carrier, Medica Choice/Insurance/Premier/Elect will reimburse eligible physician and hospital claims through the termination date of coverage.

  • In a carrier replacement situation when a member becomes effective during confinement, the previous fully insured carrier is responsible for both physician and hospital claims through a member’s discharge date, or through the date that contracted benefit maximums have been reached.

  • In all other cases, including a change of carrier, Medica Choice/Insurance/Premier/Elect will begin reimbursing eligible physician and hospital claims on the member’s effective date.

Medica Choice Care, Medica MinnesotaCare or Medica DUAL Solution

Reimbursement obligation for coverage that begins during an inpatient hospital stay for members with coverage under a Medica Choice Care, Medica MinnesotaCare or Medica DUAL Solution benefit document:

  • Medica will reimburse eligible physician or hospital claims through member’s discharge date from that facility.

Medica Prime Solution

Reimbursement obligations for coverage that begins during an inpatient hospital stay for members with coverage under a Medica Prime Solution benefit document:

  • Medica will reimburse eligible physician claims beginning with the effective date of member’s coverage.
  • Medica will not reimburse hospital claims.

Reimbursement obligations for coverage that ends during an inpatient hospital stay for members with coverage under a Medica Prime Solution benefit document:

  • Medica will reimburse eligible physician claims through termination date of member’s coverage.
  • Medica will reimburse eligible hospital claims through member’s discharge date from that facility.

Medica Select Solution

Reimbursement obligations for coverage that begins during an inpatient hospital stay for members with coverage under a Medica Select Solution benefit document:

  • Medica will reimburse eligible physician and hospital claims beginning with the effective date of member’s coverage.Reimbursement obligations for coverage that ends during an inpatient hospital stay for members with coverage under a Medica Select Solution benefit document:
  • Medica will reimburse eligible physician and hospital claims through termination date of member’s coverage.

Provider Contingency Reserve (PCR)

Clinic and physician contractual obligations regarding the Provider Contingency Reserve (PCR):

  • Medica providers have agreed that a PCR will be withheld from reimbursements for Medica Choice and Medica Premier products (excluding Medica Choice Care). Participating providers have agreed to allow Medica to use PCR funds to comply with state and federal financial reserve requirements, to comply with state-mandated expenditure growth limits, to maintain adequate operating funds and to meet other appropriate financial needs.
  • Medica determines annually, with board approval, its need for PCR funds. Providers who are participating providers for the entire term of their Medica Participation Agreement are eligible for return of PCR funds.
  • PCR will be based on actual financial results (health care cost trend versus budget), regulatory requirements and any special board action. The amount of PCR distribution will be determined by the Medica Board of Directors, based on year-end financial results.

Reimbursement for Facility Services

Contractual Obligations

Participating providers must submit claims for health services according to Medica’s administrative requirements. These include Medica’s billing requirements for coding and claim submission.

Participating facilities are bound by their Medica Participation Agreement to accept as payment in full for health services the amount reimbursed by Medica in accordance with their Medica Participation Agreement.

Refer to your Medica Participation Agreement for information about the Hospital Contingency Reserve (HCR), if applicable.

In accordance with statutory requirements and the Medica Participation Agreement, providers cannot hold any Medica member responsible for reimbursement of covered health services, except for copayment, coinsurance or deductible amounts. Facilities cannot request prepayment for services. This includes events such as breach of provider agreement or Medica’s failure to reimburse for covered health services.

When a Medica member is eligible for coverage by more than one benefit plan and Medica is the secondary carrier, reimbursement is made on the unpaid balance, up to the Medica contracted rate for facilities. The exception would be Medica’s MinnesotaCare and Choice Care members who are eligible for Medicare benefits. Per our contract with the Department of Human Services (DHS), effective with a service date of April 1, 2001, coordination of benefits includes picking up any applicable copayments, coinsurance or deductibles on behalf of the member up to the Medicare allowed amount.

Providers must cooperate with Medica’s coordination of benefits and subrogation efforts. Details regarding Coordination of Benefits are contained in the Medica Participation Agreement.

Medica will reimburse providers directly unless assignment has been made to a third party.

Medica Choice, Medica Insurance Company, Medica Premier Fully Insured or Medica Elect

Reimbursement obligations for coverage that begins or ends during an inpatient hospital stay for members with coverage under a Medica Choice, Medica Insurance Company, Medica Premier Fully Insured or Medica Elect benefit document:

  • If another plan carrier replaced Medica Choice/Insurance/Premier/Elect, Medica Choice/Insurance/Premier/Elect will reimburse eligible physician and hospital claims through the member’s discharge date from that facility.
  • In all other situations, including a change of carrier, Medica Choice/Insurance/Premier/Elect will reimburse eligible physician and hospital claims through the termination date of coverage.
  • In a carrier replacement situation when a member becomes effective during confinement, the previous fully insured carrier is responsible for both physician and hospital claims through a member’s discharge date, or through the date that contracted benefit maximums have been reached.
  • In all other cases, including a change of carrier, Medica Choice/Insurance/Premier/Elect will begin reimbursing eligible physician and hospital claims on the member’s effective date.

Medica Choice Care, Medica MinneaotaCare or Medica DUAL Solution

Reimbursement obligations for coverage that begins during an inpatient hospital stay for members with coverage under a Medica Choice Care, Medica MinneaotaCare or Medica DUAL Solution benefit document:

  • Medica will not reimburse hospital or physician claims.

Medica Choice Care, Medica MinnesotaCare or Medica DUAL Solution

Reimbursement obligations for coverage that ends during an inpatient hospital stay for members with coverage under a Medica Choice Care, Medica MinnesotaCare or Medica DUAL Solution benefit document:

  • Medica will reimburse eligible hospital or physician claims through member’s discharge date from that facility.

Medica Prime Solution

Reimbursement obligations for coverage that begins during an inpatient hospital stay for members with coverage under a Medica Prime Solution benefit document:

  • Medica will not reimburse hospital claims.
  • Medica will reimburse eligible physician claims beginning with the effective date of member’s coverage.

Reimbursement obligations for coverage that ends during an inpatient hospital stay for members with coverage under a Medica Prime Solution benefit document:

  • Medica will reimburse eligible hospital claims through member’s discharge date from that facility.
  • Medica will reimburse eligible physician claims through termination date of member’s coverage.

Medica Select Solution

Reimbursement obligations for coverage that begins during an inpatient hospital stay for members with coverage under a Medica Select Solution benefit document:

  • Medica will reimburse eligible hospital and physician claims beginning with the effective date of member’s coverage.

Reimbursement obligations for coverage that ends during an inpatient hospital stay for members with coverage under a Medica Select Solution benefit document:

  • Medica will reimburse eligible hospital and physician claims through termination date of member’s coverage.
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