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Medica Claim Submission and Product Guidelines

Select the appropriate Payer ID below to view Medica claim submission and product guidelines for each plan.

Payer ID: 94265 +

Address for Claims and Claim Appeals	Medica PO Box 30990 Salt Lake City, UT 84130-0990
Attachment/Appeal Fax#	1-801-994-1076 Claim Adjustment or Appeal Request Form (DOC)
Electronic Appeal Submission	Log in to SympliSend
Claim Numbers	5 digit groups: Claim numbers are 10 digits (CMS-1500) and 11 digits (UB-04); 6 digit groups: Claim numbers are 12 digits
Electronic Data Interchange (EDI)	Optum Intelligent EDI
Electronic Funds Transfer (EFT) Payments	Optum Health Financial Services 1-866-842-3278, option 5
Prior Authorization Submission	Prior Authorization submitted via email and/or fax number provided on the corresponding form
Inpatient Notification Submission	Medica.com Provider Portal/Admission Notification Inpatient Admission – Notification Guidelines
Referral Submission	Medica.com Provider Portal/Administrative Referral Entry for referral-based products
Clinical Guidelines	Policies and Guidelines on Medica.com
Provider Service Center	1-800-458-5512
Pharmacy	BIN/PCN/Group # vary by product – see member's ID card
Chiropractic Care	Medica PO Box 30990 Salt Lake City, UT 84130-0990 Payer ID: 94265 Benefits/Claims: Medica – 1-800-458-5512 Authorizations: Optum – 1-800-873-4575 Eligible Chiropractic Codes for Commercial and Individual Plans Only
Behavioral Health	Medica Behavioral Health (MBH): 1-800-848-8327 Medica Behavioral Health PO Box 30757 Salt Lake City, UT 84130 Payer ID: 87726
Secure Provider Portal	Medica.com - Electronic Transactions

Product Fact Sheets

Altru & You With Medica
Clear Value With Medica
Essentia Choice Care with Medica (Commercial)
Medica Choice Passport
Medica CompleteHealth
Medica Elect and Medica Essential
Medica Focus
Park Nicollet First with Medica
Ridgeview Community Network powered by Medica
VantagePlus with Medica
Medica AccessAbility Solution / Special Needs Basic Care (SNBC)
Medica AccessAbility Solution Enhanced / Special Needs Basic Care (SNBC SNP)
Medica Dual Solution/Minnesota Senior Health Options (MSHO)
Medica Choice Care MSC+/Minnesota Senior Care Plus (MSC+)
Medica Prime Solution
Medica Select Solution
Medica Signature Solution
University of Minnesota

Payer ID: 12422 +

Address for Claims and Claim Appeals	Medica Individual & Family Business PO Box 21051 Eagan, MN 55121-0051 Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “member not on file”
Attachment/Appeal Fax#	1-952-992-1427 Claim Adjustment or Appeal Request Form (DOC)
Electronic Appeal Submission	Log in to Medica Provider Portal
Claim Numbers	11 digits
Electronic Data Interchange (EDI)	Availity Client Services: 1-800-282-4548 Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “invalid eligibility for member”
Electronic Funds Transfer (EFT) Payments	InstaMed: 1-866-945-7990 Email: [email protected] Website: Register Login
Prior Authorization Submission	Prior Authorization submitted via email and/or fax number provided on the corresponding form
Inpatient Notification Submission	Fill out the Inpatient Notification Form on Medica.com Inpatient Admission – Notification Guidelines
Clinical Guidelines	Policies and Guidelines on Medica.com
Provider Service Center	1-800-458-5512
Pharmacy	ExpressScripts (ESI). BIN/PCN/Group # vary by product — see member's ID card
Chiropractic Care	Optum Chiropractic PO Box 212 Minneapolis, MN 55440-0212 Payer ID: 41161 Benefits/Claims – Medica: 1-800-458-5512 Authorizations/treatment plans are not required Eligible Chiropractic Codes for Commercial and Individual Plans Only
Behavioral Health	Medica Behavioral Health (MBH): 1-800-848-8327 Medica Behavioral Health PO Box 30757 Salt Lake City, UT 84130 Payer ID: 87726
Secure Provider Portal	Medica.com – Electronic Transactions

Product Fact Sheets

Altru Prime by Medica
Balance by Medica
Bold by M Health Fairview
Elevate by Medica
Empower by Medica
Engage by Medica
Essentia Choice Care with Medica (Individual and Family Business)
Harmony by Medica
Inspire by Medica
Medica Applause
Medica Connect
Medica Direct HSA
Medica Direct Value
Medica Encore
Medica Individual Choice
Medica Insure
Medica Pinnacle
Medica Quest
Medica Solo
Medica Symphony HSA
Medica with CHI Health
Medica with MU HealthCare
North Memorial Acclaim by Medica
Ridgeview Distinct by Medica
Select by Medica

Payer ID: 71890 +

Address for Claims and Claim Appeals (paper submission and correspondence)	Medica PO Box 211435 Eagan, MN 55121 Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “member not on file”
Attachment/Appeal Fax#	952-992-3024 Claim Adjustment or Appeal Request Form (DOC)
Electronic Appeal Submission	Log in to Medica Provider Portal.
Claim Numbers	13 digits
Electronic Data Interchange (EDI)	Availity Client Services: 1-800-282-4548 Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “invalid eligibility for member”
Electronic Funds Transfer (EFT) Payments	InstaMed: 1-866-945-7990 Email: [email protected] Website: Register Login
Prior Authorization Submission	Prior authorization submitted via email and/or fax number provided on the corresponding form
Inpatient Notification Submission	Fill out the Inpatient Notification Form on Medica.com Inpatient Admission – Notification Guidelines
Clinical Guidelines	Policies and Guidelines on Medica.com
Provider Service Center	1-800-458-5512
Pharmacy	Varies by product – see member's ID card
Chiropractic Care	Varies by product – see member's ID card Note: Effective 1/1/2024, chiropractic claims for Mayo and Medica Health Plan Solutions products in MN/WI should be submitted to EDI# LNDMK or Fulcrum Health, Inc. P.O. Box 981808, El Paso, TX 79998-1808. This information is not reflected on the ID Card. Questions? Contact Fulcrum at 1 (877) 886-4941, option 9, or by e-mail at [email protected].
Behavioral Health	Any provider within the available networks (see applicable provider fact sheet below for directory).
Secure Provider Portal	Medica.com – Electronic Transactions

Product Fact Sheets

Mayo Medical Plan
Medica Choice National
Medica with CHI Health Fact Sheet (Accountable Care System Product)
Medica Health Plan Solutions

Payer ID: 53589 – AZ +

Address for Claims and Claim Appeals (paper submission and correspondence)	Medica PO Box 211435 Eagan, MN 55121 BCBS AZ providers submit to payer ID 53589 Mayo Clinic providers submit to payer ID 71890
Attachment/Appeal Fax#	952-992-3024 Claim Adjustment or Appeal Request Form (DOC)
Claim Numbers	13 digits
Electronic Appeal Submission	Log in to Medica Provider Portal.
Electronic Data Interchange (EDI)	BCBS AZ providers submit to payer ID 53589 Mayo Clinic providers submit to payer ID 71890
Electronic Funds Transfer (EFT) Payments	InstaMed: 1-866-945-7990 Email: [email protected] Website: Register Login
Prior Authorization Submission	Prior Authorization submitted via email and/or fax number provided on the corresponding form
Inpatient Notification Submission	Fill out the Inpatient Notification Form on Medica.com Inpatient Admission – Notification Guidelines
Clinical Guidelines	Policies and Guidelines on Medica.com
Provider Service Center	1-800-458-5512
Pharmacy	Alluma 1-833-789-5310 BIN/PCN/Group # vary by product – see see member's ID card
Chiropractic Care	BCBS AZ provider network Payer ID: 53589
Behavioral Health	BCBS AZ provider network Payer ID: 53589
Secure Provider Portal	Medica.com – Electronic Transactions

Product Fact Sheet

Mayo Medical Plan AZ

Payer ID: 88090 – FL +

Claim Address (paper submission and correspondence)	Zelis/Medica PO Box 2839 Farmington Hills, MI 48333 Zelis providers submit to payer ID 88090 Mayo Clinic providers submit to payer ID 71890
Address for Claim Appeals	Medica PO Box 211435 Eagan, MN 55121
Attachment/Appeal Fax#	952-992-3024 Claim Adjustment or Appeal Request Form (DOC)
Electronic Appeal Submission	Log in to Medica Provider Portal.
Claim Numbers	13 digits
Electronic Data Interchange (EDI)	Zelis providers submit to payer ID 88090 Mayo Clinic providers submit to payer ID 71890
Electronic Funds Transfer (EFT) Payments	InstaMed: 1-866-945-7990 Email: [email protected] Website: Register Login
Prior Authorization Submission	Prior Authorization submitted via email and/or fax number provided on the corresponding form
Inpatient Notification Submission	Fill out the Inpatient Notification Form on Medica.com Inpatient Admission – Notification Guidelines
Clinical Guidelines	Policies and Guidelines on Medica.com
Provider Service Center	1-800-458-5512
Pharmacy	Alluma 1-833-789-5310 BIN/PCN/Group # vary by product – see member's ID card
Chiropractic Care	Zelis provider network Zelis/Medica PO Box 2839 Farmington Hills, MI 48333 Payer ID: 88090
Behavioral Health	Any available provider within the Zelis network Zelis/Medica PO Box 2839 Farmington Hills, MI 48333 Payer ID: 88090
Secure Provider Portal	Medica.com – Electronic Transactions

Product Fact Sheet

Mayo Medical Plan FL

Payer ID: MEDM1 +

Address for Claims and Claim Appeals	Medica Government Programs PO Box 21342 Eagan, MN 55121-0342 Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “member not on file”
Attachment/Appeal Fax#	952-992-3899 Claim Adjustment or Appeal Request Form (DOC)
Electronic Appeal Submission	Log in to Medica Provider Portal.
Claim Numbers	13 digits
Electronic Data Interchange (EDI)	Availity Client Services: 1-800-282-4548 Note: When submitting claims under this payer ID, use only the 10-digit member ID. If you include the 2-digit suffix for the member, the claim will reject as “invalid eligibility for member”
Electronic Funds Transfer (EFT) Payments	InstaMed: 1-866-945-7990 Email: [email protected] Website: Register Login
Prior Authorization Submission	Prior Authorization submitted via email and/or fax number provided on the corresponding form
Inpatient Notification Submission	Fill out the Inpatient Notification Form on Medica.com Inpatient Admission – Notification Guidelines
Clinical Guidelines	Policies and Guidelines on Medica.com
Provider Service Center	1-800-458-5512
Pharmacy	Medicare Advantage Solution: Rx Bin: 003858 Rx PCN: MD Rx Group: 2Medica Medicaid Families and Children: Rx Bin: 003858 Rx PCN: MA Rx Group: 3Medica
Chiropractic Care	Benefits/Claims – Medica: 1-800-458-5512 Authorizations – Optum: 1-800-873-4575 Optum Chiropractic PO Box 212 Minneapolis, MN 55440-0212 Payer ID: 41161
Behavioral Health	Medica Behavioral Health (MBH): 1-800-848-8327 Medica Behavioral Health PO Box 30757 Salt Lake City, UT 84130 Payer ID: 87726
Dental (Medicaid Families and Children only)	Delta Dental PO Box 9120 Farmington Hills, MI48333-9120 Payer ID: 07000
Secure Provider Portal	Medica.com – Electronic Transactions

Product Fact Sheets

Medica Advantage Solution HMO Fact Sheet
Medica Advantage Solution HMO-POS Fact Sheet
Medica Advantage Solution and Medica Advantage PPO Fact Sheet
Medica Choice Care^SM PMAP & Medica MinnesotaCare Fact Sheet

Payer ID: 41822 +

Address for Claims and Claim Appeals	Medica PO Box 211404 Eagan, MN, 55121
Attachment/Appeal Fax#	Fax to 952-992-2836 or E-Mail to [email protected] Utilization Management and Clinical Appeals PO Box 9310 CP440 Minneapolis, MN 55440
Electronic Appeal Submission	Dean Health Plan: providerauth.deancare.com Prevea360: providerauth.prevea360.com Medica (formerly known as WellFirst): providerauth.mo-central.medica.com
Claim Numbers	Claim numbers are 13 digits
Electronic Data Interchange (EDI)	Availity Client Services: 1-800-282-4548
Electronic Funds Transfer (EFT) Payments	InstaMed: 1-866-945-7990 Email: [email protected] Website: Register Login
Prior Authorization Submission	Prior authorization submission details can be found here: Dean Health Plan: www.deancare.com/providers/medical-management Prevea360: www.prevea360.com/Providers/Med-Management Medica (formerly known as WellFirst): www.mo-central.medica.com/Providers/Medical-Management
Inpatient Notification Submission	Does not apply to payer 41822
Referral Submission	Does not apply to payer 41822
Clinical Guidelines	Dean Health Plan: www.deancare.com/providers/medical-management Prevea360: www.prevea360.com/Providers/Med-Management Medica (formerly known as WellFirst): www.wellfirstbenefits.com/Providers/Medical-Management
Provider Service Center	1-800-458-5512
Pharmacy	Navitus: 866-333-2757 BIN/PCN/Group # vary by product – see member's ID card
Chiropractic Care	Medica PO Box 211404 Eagan, MN, 55121 Payer ID: 41822 Benefits/Claims/Authorizations: Medica – 1-800-458-5512
Behavioral Health	Medica PO Box 211404 Eagan, MN, 55121 Payer ID: 41822 Benefits/Claims/Authorizations: Medica – 1-800-458-5512

Product Fact Sheets

Dean Health Plan Focus EPO Fact Sheet
Dean Health Plan HMO Fact Sheet
Medica (formerly WellFirst Health) Fact Sheet
Prevea360 Fact Sheet