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Medica Administrative Manual Home > Network Operation and Support Services > Credentialing and Demographics

Credentialing and Demographics

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.


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:

Medica requires a recredentialing/reappointment application every three years. 

There are several ways to submit your recredentialing/reappointment application:

  1. Apply through the Minnesota Credentialing Collaborative (MCC)
  2. Complete the Minnesota Uniform Credentialing Reappointment Application (PDF) and email to Credentialing_Apps@medica.com
  3. Complete your state-specific recredentialing/reappointment application and include the Authorization and Release Form (PDF) and email to Credentialing_Apps@medica.com

Demographic Changes

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

Centers for Medicare and Medicaid Services (CMS) rules require that providers keep their demographic data up-to-date to ensure accuracy for Medica's systems and provider directories.

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 Medica requests via email send to MedicaDemoFormSubmis@medica.com

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

1.  Use our secure Provider Demographic Update Online Tool (PDOT)

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           

For more about using PDOT see the PDOT User Guide (PDF) or contact the Provider Service Center at 1-800-458-5512.

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: 

Email: MedicaDemoFormSubmis@medica.com

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

To add or update an interpreter, you must submit your changes to us using our secure Provider Demographic-Update Online Tool (PDOT).

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

For more about using PDOT see the PDOT User Guide (PDF) or contact the Provider Service Center at 1-800-458-5512.

To add or update a PCA, you must submit your changes to us using our secure Provider Demographic-Update Online Tool (PDOT).

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

For more about using PDOT see the PDOT User Guide (PDF) or contact the Provider Service Center at 1-800-458-5512.

To add or update a facility, you must currently be a contracted provider with Medica. Not currently contracted with Medica? Learn how to join our network.

Providers must update their site-level demographic data as soon as they know of a change to that data as well as regularly review their demographic information for accuracy.

The Centers for Medicare and Medicaid Services (CMS) rules require accurate information for Medica's provider directories as well as regular updates to them.

How to Submit a Request

There are two ways to add or update clinic demographic data*:

For more information about making demographic changes, contact the Provider Service Center at 1-800-458-5512.

*Demographic updates including check address and tax ID changes also need to 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 the Secure Electronic Transactions login page.



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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