July 2015
General News
Prior authorization requests to require ICD-10 codes
Medica has updated its Prior Authorization Request Form to include ICD-10 diagnosis codes. Going forward, Medica encourages providers to indicate ICD-10 codes when dates of service for Medica members will begin on or after October 1, 2015. Providers should include ICD-9 codes for services through September 30, 2015. See the Prior Authorization Request Form.
Note: If a prior authorization was obtained prior to October 1, 2015, for services continuing until October 1, 2015, or beyond, and the authorization was initially approved with an ICD-9 code, the authorization will continue to be in effect as confirmed in each case by Medica.
Reminder
Current process for timely filing to apply for ICD-10 claims
112 days until go-live date arrives!
All providers must submit ICD-10 diagnosis and inpatient procedure codes beginning with October 1, 2015, dates of service (or dates of discharge). Claims without ICD-10 diagnosis and inpatient procedure codes as of that date cannot be processed and will not be accepted. ICD-9 codes will be accepted through September 30, 2015, dates of service (or dates of discharge).
The current timely-filing process will continue to apply for claims submitted to Medica, and no extensions will be granted.
For more ICD-10 resources:
- See roadto10.org »
- See medica.com »
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Clinical News
Effective May 20, 2015:
Medica makes coverage policy change
The following benefit determination was effective beginning with May 20, 2015, dates of service. This change applies to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Coronary computed tomography angiography (CCTA)
Medica has reviewed cardiac computed tomography for evaluation of cardiac structure and morphology and has determined that this technology will no longer be managed. Medica also has reviewed CCTA for coronary artery evaluation and has determined that this technology is no longer investigative and is therefore covered for high-risk symptomatic patients. CCTA for screening of asymptomatic patients, with or without risk factors, remains investigative and therefore not covered. The new determination is reflected in the revised and newly titled coverage policy “Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation,” formerly titled “Cardiac Computed Tomography and Coronary Computed Tomography Angiography (CCTA).
CCTA involves the use of multi-slice or multi-detector row computed tomography and intravenously administered contrast material to obtain detailed images of the blood vessels of the heart. It has been used as a noninvasive alternative to conventional invasive coronary angiography for evaluating coronary artery disease and coronary artery anomalies.
The complete text of the policy that applies to the determination above is available online or on hard copy:
- See coverage policies at medica.com; or
- Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355.
Effective June 1, 2015:
Medica inactivates UM policy
Medica recently made a change to the following utilization management (UM) policy, effective beginning with June 1, 2015, dates of service. This change applies to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Vacuum-assisted negative pressure wound therapy
After reviewing vacuum-assisted negative pressure wound therapy, Medica has determined that this technology no longer requires prior authorization. The related UM policy, "Vacuum-Assisted Negative Pressure Wound Therapy," has been inactivated.
Medica previously notified providers about this change with a Provider Alert in late May 2015.
Non-powered and/or single-use systems, such as the SNaP™ Wound Care System or the PICO™ single-use system, remain investigative and therefore not covered, as addressed in the coverage policy "Non-Powered or Single Use Negative Pressure Wound Therapy Systems."
Vacuum-assisted closure is a technique designed to promote the healing of open wounds that are refractory to standard treatment. The treatment consists of a computerized vacuum pump that delivers localized, continuous or intermittent, subatmospheric pressure to the wound through tubing attached to a foam dressing positioned in the wound cavity or over a flap or graft. The free end of the drainage tube is attached to a fluid collection canister.
Effective August 1, 2015:
Medica to implement new coverage policy
The following benefit determination will be effective beginning with August 1, 2015, dates of service. This new policy will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Subcutaneous implantable cardioverter-defibrillator (S-ICD)
Medica has reviewed S-ICD and has determined that this technology is investigative and therefore will not be covered.
The S-ICD system is designed to monitor and treat cardiac arrhythmias (abnormal heartbeat) and to reduce the risks of sudden cardiac arrest and sudden cardiac death.
The S-ICD system is a new-generation ICD that does not require transvenous insertion; the wire electrode is instead placed under the skin above the sternum. The electrode is attached to a generator which is inserted under the skin and implanted outside the rib cage. When the device detects a life-threatening heart arrhythmia, it delivers a shock via the electrode to the subcutaneous tissue of the chest in order to restore the heart’s normal rhythm. This is less invasive and differs from the standard implantable defibrillator electrode wire that is inserted in a vein and directly into the heart. One other difference is that the S-ICD does not have pacemaker capabilities because it lacks heart electrodes. The S-ICD is usually inserted using local anesthesia with sedation and requires an overnight hospitalization.
The complete text of the policy that applies to the determination above will be available online or on hard copy:
Effective August 1, 2015:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective August 1, 2015, unless otherwise noted.
UM policies — Inactivated
| Name |
Policy Number |
| Vacuum-Assisted Negative Pressure Wound Therapy (effective 6/1/15) |
III-DEV.21 |
Coverage policies — New
| Name |
| Subcutaneous Implantable Cardioverter-Defibrillator (S-ICD) |
Coverage policies — Revised
These versions replace all previous versions.
| Name |
| Extracorporeal Photopheresis (Photochemotherapy) |
| Therapeutic Apheresis — Plasmapheresis, Plasma Exchange |
| Coronary Computed Tomography Angiography (CCTA ) for Coronary Artery Evaluation (effective 5/20/15 — formerly Cardiac Computed Tomography (CT) and Coronary Computed Tomography Angiography (CCTA)) |
| In Vitro Chemosensitivity and Chemoresistance Assays |
| Topographic Genotyping (PathFinder TG®) for Diagnosis of Cancer |
Coverage policies — Inactivated
| Name |
| AmniSure® for Detection of Fetal Membrane Rupture |
These documents will be available online or on hard copy:
The importance of well-child visits for children and teens
The American Academy of Pediatrics (AAP) has updated its schedule of screenings and health assessments that are recommended at each child visit from infancy through adolescence in 2014. These recommendations are promoted through “Bright Futures,” an AAP initiative that outlines preventive health needs for children and adolescents. Bright Futures is also supported by the Maternal and Child Health Bureau and the Health Resources and Services Administration. Bright Futures Guidelines provide theory-based and evidence-driven guidance for all preventive care screenings and well-child visits. See more from the Bright Futures website.
To help patients make the most of the well-child visit, it should be viewed as a team approach with the parent. The guidelines are designed for care of children and adolescents who are receiving competent parenting, with no manifestations of any important health problems or variations from the normal. Children and adolescents with developmental, psychosocial and chronic disease issues may require frequent counseling and treatment visits separate from preventive care visits. Providers may also wish to review milestones, immunizations, depression screening, alcohol and drug use assessment, and other recommended tests (such as vision and hearing).
In addition, the State of Minnesota uses “Preventive Services for Children and Adolescents” as its guideline for children and teens on Medicaid. These criteria, known as Child and Teen Checkups (C&TC), were adopted from the Institute for Clinical Systems Improvement (ICSI) and are supported by Medica for its members enrolled in Minnesota Health Care Programs (MHCP).
Some of the important areas to consider during a well-child or teen visit are:
- The assessment of a child’s health begins with a prenatal visit. Obtain a good family history of the parents and discuss feeding choices such as breastfeeding, formula or bank breast milk.
- Conduct early hearing and vision detection on the child and, if needed, interventions.
- Identify and evaluate children with autism spectrum disorders (this should begin when the child is a toddler).
- Ensure the immunization schedule is up-to-date.
- Check for lead poisoning at 12 months and 2 years of age.
- Check the child’s hemoglobin at 12 months of age.
- Consider cardiovascular health and risk reduction in children and adolescents, as well as monitoring cholesterol.
- Consider weight issues.
- Check oral health.
- Use screening tools to assess adolescents’ for depression, anxiety, and alcohol and drug use.
- Screen for HIV between 16 and 18 years of age.
Providers should remember to use these visits as an opportunity to discuss and use Bright Futures guidelines to help educate the parents and child or teen on continuing good health.
Due by July 15, 2015:
Quality complaint reports required by State of Minnesota
Medica requires its Minnesota-based network providers to submit second-quarter 2015 quality-of-care complaint reports to Medica by July 15, 2015.
The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form). Providers may send reports by fax to 952-992-3880 or by mail to:
Medica Quality Improvement
Mail Route CP405
PO Box 9310
Minneapolis, MN 55440-9310
Report forms are available by:
Note: Providers submitting a report for multiple clinics should list all the clinics included in the report. Providers who have questions about the complaint reporting process may:
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Administrative News
Effective August 1, 2015:
Credentialing to add new provider specialty designation
Effective August 1, 2015, Medica will add a new practitioner specialty to identify practitioners as part of their provider demographics (for instance, available in provider directories for Medica members to use). The new specialty is Sports Medicine. Practitioners with the appropriate training or education who would like to request Sports Medicine as their specialty can do one of the following:
- If already credentialed with Medica, submit a Minnesota Uniform Practitioner Change Form to [email protected].
- If new to the Medica network, contact the Medica Credentialing department at [email protected].
Best practice: Use of taxonomy codes on claims
Medica encourages providers to use taxonomy codes on claims whenever these codes have an impact on claims processing. Doing so supports best practices for claims submission, as outlined by the Minnesota Administrative Uniformity Committee (AUC). Taxonomy codes reflect the 10-digit alpha/numeric codes that enable providers to identify their specialty at the claim level. When providers include the taxonomy codes, it results in more accurate and faster claims processing, so Medica can make payments to providers more quickly.
Loops, segments and elements for taxonomy codes
Taxonomy codes should be submitted according to AUC best-practice guidelines:
- 837P: 2000A, PRV (Billing/Pay-To Provider) 2310B, PRV (Rendering Provider) 2420A, PRV (Rendering Provider)
- 837I: 2000A, PRV (Billing/Pay-To Provider) 2310A, PRV (Attending Provider)
See more details from the AUC about the submission of taxonomy codes.
Effective May 17, 2015:
Medica revises reimbursement policy
Medica has recently updated the reimbursement policy indicated below, effective with May 17, 2015, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Ambulance (updated code list) |
This revised policy is available online or on hard copy:
Effective May 24, 2015:
Medica revises reimbursement policy
Medica has recently updated the reimbursement policy indicated below, effective with May 24, 2015, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Services and Modifiers Not Reimbursable to Health Care Professionals (updated code list) |
This revised policy is available online or on hard copy:
Reminder:
Facilities required to report adverse health care events
If an adverse health care event (also known as a “never event”) involving a Medica member occurs, all facilities are expected to follow the “Adverse Health Care Events” reimbursement policy. According to this policy, facilities are prohibited from billing members for services associated with an adverse health care event. If such an event involving a Medica member occurs, facilities are also required to fill out and submit an Adverse Health Care Event Identification Form to Medica. In addition, all facilities must maintain, and comply with, policies and procedures that address the reporting of adverse health care events, as outlined in Minnesota statutes.
The Adverse Health Care Events reimbursement policy includes further details, including a description of each applicable event and the Adverse Health Care Event Identification Form. See the full Adverse Health Care Events policy on medica.com.
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PPO News
Latest UHC provider bulletin online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (May 2015). Highlights that may be of interest to LaborCare® network providers include:
- Hospital quality information now available through myHealthcare Cost Estimator
- Reminder about prior authorization for injectable chemotherapy — effective in June 2015
- New Procedure and Place of Service Policy — scheduled for September 2015
View the May 2015 UHC provider bulletin.
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