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Credentialing and Demographics

Important Note for Non-Direct or MMSI Credentialed Providers

MMSI Providers

For practitioners currently credentialed by MMSI, no action is required until your MMSI recredentialing date occurs. If you are not currently credentialed by MMSI, follow Medica’s credentialing process below.

Leased Network Providers

Providers who are part of a leased network that contracts with Medica, such as a preferred provider organization (PPO), should work with their network’s administrative office to update demographics with Medica. This page applies to direct contract providers only.

Not Currently Contracted With Medica?

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Credentialing

We determine which physicians and allied health professionals and facilities are accepted for participation in Medica networks. The Credentialing Plan outlines the standards, policies, and process for the acceptance, discipline, and termination of participating practitioners and organizational providers.

Credentialing determinations are guided by an evaluation of each practitioner's capability to provide comprehensive, safe, effective, efficient, and quality care to Medica members, in light of the practitioner’s background, credentials and qualifications.

Credentialing plan (PDF)

Practitioners have options for submitting their credentialing applications to Medica.

See how to submit your credentialing applications:

NEW: Download a locum tenens application for all states.

Medica requires a recredentialing/reappointment application every three years. 

There are several ways to complete a recredentialing/reappointment application:

  1. Apply through the Minnesota Credentialing Collaborative (MCC)

  2. Complete the Minnesota Uniform Credentialing Reappointment Application (PDF) and submit to Medica

  3. Complete your state-specific recredentialing/reappointment application and submit it to Medica along with the Authorization and Release Form (PDF)

  4. Apply through the Council for Affordable Quality Healthcare® (CAQH) website, and then submit the following items to Medica:

    • Name
    • CAQH ID
    • National Provider Identifier (NPI) number

Submit documents to Medica via email


Demographic Changes

Providers need to regularly review their demographic information for accuracy and notify us of as soon as they know of a change to that data.

Keeping demographic data up-to-date ensures accuracy for Medica's systems and provider directories. This requirement is based on Centers for Medicare and Medicaid Services (CMS) rules, Qualified Health Plan (QHP) and Federally Facilitated Exchange standards, and in accordance with applicable state laws, including Minnesota network-adequacy statutes.

To see which practitioner types Medica credentials, view the Credentialing Plan (PDF).

To add a practitioner to an existing Medica location, use the Uniform Practitioner Change Form (DOC).

To submit requests to Medica via email, send to MedicaDemoFormSubmis@medica.com.

There are two options for submitting any updates to a credentialed or non-credentialed provider:

1.  Log into Electronic Transactions to update provider demographics

This tool is used to submit the following types of changes: 

  • Add a practitioner to an additional practice location
  • Remove a practitioner from a practice location 
  • Add, change or correct basic practitioner demographic data           

Learn more about how to update provider demographics (PDF)

2.  Complete our Uniform Practitioner Change Form (PDF)

Once you have completed the Uniform Practitioner Change Form, you can submit it to us via email or mail: 

MedicaDemoFormSubmis@medica.com

Medica Provider Demographics
Route CP425
P.O. Box 9310
Minneapolis, MN 55440-9310

To add or update an interpreter, you must submit your changes online.

Log into Electronic Transactions to update interpreter information

This form is used to submit the following types of changes:

  • Add a practitioner to an additional practice location
  • Remove a practitioner from a practice location
  • Add, change or correct basic practitioner demographic data such as:
    • Legal name
    • Social Security number
    • Minnesota Department of Health (MDH) Interpreter Roster ID
    • Languages spoken fluently

Learn more about how to update interpreter information (PDF)

To add or update a PCA, you must submit your changes online.

Log into Electronic Transactions to update PCA information

This form is used to submit the following types of changes:

  • Add a practitioner to an additional practice location
  • Remove a practitioner from a practice location
  • Add, change or correct basic practitioner demographic data such as:
    • Legal name
    • Social Security number
    • Unique Minnesota Provider Identifier (UMPI) number
    • Languages spoken fluently

Learn more about how to update PCA information (PDF)

To add or update a facility, you must currently be a contracted provider with Medica. 

Providers need to regularly review their site-level demographic information for accuracy and notify us of as soon as they know of a change to that data. The Centers for Medicare and Medicaid Services (CMS) rules require accurate information for Medica's provider directories as well as regular updates to them.

Any demographic updates that include check address and tax ID changes also must be made as part of the Electronic Payments and Statements (EPS) electronic transaction as well as the Medicalis high-tech imaging system, for those providers enrolled in these programs. The PDOT, EPS and Medicalis systems are separate and need to be updated individually when such changes occur. All of these systems are available through our Electronic Transactions.

How to Submit a Request

For Providers With Access to Electronic Transactions 

Learn more about how to update facility information (PDF) 

For Providers Without Access to Electronic Transactions 

 


Data Validation

Maintaining current and accurate provider demographic data in our systems and databases is a critical factor in accurate and timely claims payment, as well as the printing and distribution of accurate and current provider directories.

Upon request, Medica will prepare a demographic data validation report in an electronic spreadsheet based on a provider's tax ID number and then send it to the provider.

Providers can then verify the information contained in the validation report to ensure that Medica has accurate and current demographic data.

Clinics or sites that are interested in participating in this project are invited to contact our Provider Operations team at MedicaDemoResolution@medica.com. Providers should include contact name, phone number, clinic name and tax ID.

Provider Directories

It is important that patients and members have access to accurate, up-to-date information when seeking care in their provider network. Providers need to regularly update their demographic data based on the Centers for Medicare and Medicaid Services (CMS ) rules.

To ensure that members have the best experience possible when looking for care, health plans need providers’ help to ensure provider details and clinic locations are up-to-date. Providers should update their practitioner and site-level information regularly or as soon as they know of a change to that data. Information in Medica’s provider directories can be reviewed and edited through the secure Provider Demographic-Update Online Tool (PDOT) or the Add/Term/Change (ATC) Form (DOC).

One key element for accuracy in provider directories is for providers to indicate exactly where their practitioners see patients. Site-specific practitioner information needs to be accurate so when members call a site and ask for a doctor, they don’t find out the doctor doesn’t provide services there.


 

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