May 2017
General News
Reminder:
Medica MHCP membership to change after April 30
As previously published, Medica is withdrawing from Minnesota's Medicaid program for families and children, effective April 30, 2017. This change will specifically apply to Medicaid populations enrolled in Medica products for MinnesotaCare and Medical Assistance (MA), also known as the Prepaid Medical Assistance Plan (PMAP). As a result, coverage for more than 300,000 Minnesotans will change to another health plan as of May 1, 2017.
This change will not affect the following Medica members enrolled in Minnesota Health Care Programs (MHCP):
- Medica AccessAbility Solution®(SNBC)
- Medica DUAL Solution®(MSHO)
- Medica Choice Care MSC+
These three groups of MHCP enrollees will continue to have Medica coverage after April 30, 2017. Medica published more about this in a recent Provider Alert.
The upcoming change to Medica's MinnesotaCare and MA membership will be effective with the April 30 date of termination of Medica's contract with the Minnesota Department of Human Services (DHS). As a result, claims with dates of service on or after May 1, 2017, will no longer be paid by Medica for services provided to Medica's MinnesotaCare and MA members. For services provided through April 30, providers can continue to submit claims to Medica for payment. All original claims must be received by Medica no more than 180 days after the date of service or date of discharge for inpatient claims. Medica will also be responsible for inpatient hospital claims for these members beyond April 30 if they are admitted prior to that date.
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Clinical News
Preventing STIs: chlamydia screening and HPV vaccination
Chlamydia and human papillomavirus (HPV) are two of the most frequently reported infectious diseases, and both are sexually transmitted infections (STIs). They can have dire consequences, not only for the person infected, but also possibly for a partner or child if it's transmitted.
Screening to prevent the spread of chlamydia
Chlamydia is often asymptomatic in both women and men. Chlamydia screening is recommended by the U.S. Preventive Services Task Force (USPSTF) for all sexually active women age 25 years or less and in older women who are at risk for the infection (such as having a new sex partner or who have more than one sex partner). In men, targeted screening is recommended where the prevalence of chlamydia is high or if the patient has had sex with an infected partner.
This infection has serious consequences if left untreated, which include Pelvic Inflammatory Disease (PID), ectopic pregnancy, miscarriage and/or preterm labor and infertility. If a woman gives birth and has chlamydia, the child is at high risk for various infections such as infections involving the mucous membranes of the eye, oropharynx, urogenital tract and rectum, as well as afebrile pneumonia with onset at one to three months of age. If an infant has conjunctivitis at an age of 30 days or less, the infant should receive evaluation and appropriate care and treatment for possible chlamydial infection. In males, chlamydia can damage sperm and cause scarring in the reproductive tract, which could lead to infertility. When treated, before complications develop, it may not cause any long-term problems.
Treatment for chlamydia is administered through antibiotics. A meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline for a seven-day treatment demonstrated effectiveness with cure rates of 97 percent and 98 percent respectively. The Centers for Disease Control and Prevention (CDC) recommends follow-up testing in three to four weeks after completing antibiotic therapy.
Vaccinating to prevent the spread of HPV
HPV is another virus that is transmitted through intimate skin-to-skin contact. There are more than 150 related viruses. About 30 types of this virus put a person at risk for cancer. Low-risk HPV can cause genital warts or recurrent respiratory papillomatosis (RRP). High-risk HPV can lead to cancers in women of the cervix, vulva, vagina and anus and in men can lead to cancer of the penis. Both women and men could get cancer of the anus/rectum or mouth/throat including tongue and tonsils (oropharyngeal cancer).
Each year, about 38,793 new cases of cancer are found in parts of the body where HPV is often found and causes about 30,700 deaths. These cancers maybe preventable if patients are vaccinated as recommended. HPV vaccines are recommended by the CDC for preteen girls and boys.
Effective July 1, 2017:
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 July 1, 2017, unless otherwise noted.
As previously published, Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits. Medica will begin using the 21st edition of MCG Care Guidelines on July 1, 2017, resulting in changes to several policies, as noted below.
UM policies — Inactivated
| Name |
Policy number |
| Human Leukocyte Antigen-DQ (HLA-DQ) Genetic Testing for Celiac Disease (effective 4/19/17) |
III-DIA.10 |
UM policies — Revised
These versions will replace all previous versions.
| Name |
Policy number |
| Behavioral Health Services – Individual and Family Business (update to MCG 21st edition) |
III-BEH.01 |
| Extended Hours Home Care (update to MCG 21st edition) |
III-HOM.01 |
| Genetic Testing for Susceptibility to Colorectal Cancer (CRC) Syndromes (update to MCG 21st edition) |
III-DIA.06 |
| Hip Arthroplasty/Replacement and Hip Resurfacing (update to MCG 21st edition) |
III-SUR.40 |
| Implantable Deep Brain Stimulation (update to MCG 21st edition) |
III-DEV.19 |
| Inpatient (Hospital) Level of Care (update to MCG 21st edition) |
III-INP.01 |
| Inpatient Rehabilitation Facility (Acute Rehabilitation) (update to MCG 21st edition) |
III-INP.05 |
| Long Term Acute Care Hospital (LTACH) (update to MCG 21st edition) |
III-INP.04 |
| Maternal Plasma Tests for Detection of Cell-free Fetal DNA for Analysis of Chromosomal Aneuploidies (update to MCG 21st edition) |
III-DIA.11 |
| Orthognathic Surgery (update to MCG 21st edition) |
III-SUR.32 |
| Proton Beam Radiation Therapy (update to MCG 21st edition) |
III-MED.06 |
| Skilled Nursing Facility (update to MCG 21st edition) |
III-INP.03 |
| Thoracic Sympathectomy for Primary Hyperhidrosis (update to MCG 21st edition) |
III-SUR.25 |
| Vagus Nerve Stimulation (update to MCG 21st edition) |
III-DEV.24 |
| Wheelchairs, Scooters & Accessories (update to MCG 21st edition) |
III-DEV.25 |
Coverage policies — New
| Name |
| Human Leukocyte Antigen-DQ (HLA-DQ) Genetic Testing for Celiac Disease (effective 4/19/17) |
Coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Continuous Glucose Monitoring (CGM) Systems for Managing Diabetes |
| Cranial Electrotherapy Stimulation (CES) |
| Radiofrequency Volumetric Tissue Reduction (RFVTR) for Obstructive Sleep Apnea |
| Trigger Point Dry Needling |
These documents will be available online or on hard copy:
Note: In addition, Medica may make changes to one or more medical policies effective July 17, 2017. Monthly updates to Medica's policies will be available on an ongoing basis. Updates will be posted on medica.com prior to their effective date.
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Pharmacy News
Effective June 10, 2017:
Medica to implement new drug coverage policy
Medica will soon implement the following drug coverage policy, effective with June 10, 2017, dates of service, unless otherwise noted.
Drug coverage policies — New
| Name |
| Eteplirsen (Exondys 51) |
Medica published more about this change in a recent Provider Alert.
This new drug coverage policy is available online or on hard copy:
Effective July 1, 2017:
Medica plans to update member formularies
Medica is reviewing several medications and will potentially be making changes in coverage status to drug formularies (or drug lists) effective July 1, 2017. For certain Medica members, as noted below, these changes would be effective July 1, 2017, for new prescriptions, but not effective until August 1, 2017, for existing prescriptions.
These upcoming changes may apply to one or more of the following drug formularies:
- 2017 Medica Commercial Large Group Drug List - effective 7/1 for new prescriptions, 8/1 for existing prescriptions
- 2017 Medica Commercial Small Group Drug List
- 2017 Medica Preferred Drug List for individual and family business (IFB)
- 2017 Medica List of Covered Drugs for Minnesota Health Care Programs (MHCP) - effective 7/1 for new prescriptions, 8/1 for existing prescriptions
The Medica MHCP formulary applies to the following products: Medica Choice CareSM (for Minnesota Senior Care Plus program, or MSC+), Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. More about upcoming changes that will apply to Medica Medicare Part D formularies is included below.
Medica will post changes to its drug formularies on medica.com prior to their effective date. To see the latest Medica drug list changes as well as full drug formularies for each member type, refer to medica.com.
Medication request forms
A formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can submit an exception form or call CVS Caremark.
Effective July 1, 2017:
Upcoming changes to Medica Part D drug formularies
Medica posts changes to its Part D drug formularies on medica.com prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective July 1, 2017. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. These latest changes will be posted soon. View the latest Medicare Part D drug formulary changes.
Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:
Medication request forms
A medication request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can submit an exception form or call CVS Caremark.
Effective July 1, 2017:
Medica to add new UM policies for medical pharmacy drugs
Medica will soon implement the following new medical pharmacy drug utilization management (UM) policies. These changes will be effective with July 1, 2017, dates of service, unless otherwise noted. Prior authorization will be required for the corresponding medical pharmacy drugs. These UM changes will apply to relevant prior authorization and pre-payment claims edit policies.
Medical pharmacy drug UM policies — New
Prior authorization will be required.
| Drug code |
Drug brand name |
Drug generic name |
| J9999 |
Bavencio |
avelumab |
| J9999 |
Lartruvo |
olaratumab |
| J3590 |
Ocrevus |
ocrelizumab |
| J3590 |
Spinraza (effective 3/17/17; see details) |
nusinersen |
| J3490 |
Sustol |
granisetron ER |
| J9999 |
Tecentriq |
atezolizumab |
These policies will apply to Medica commercial, Minnesota Health Care Programs (MHCP) and individual and family business (IFB) members, but not to Medica Medicare members. All of these policies will be subject to pre-payment claims edits as well.
The new medical pharmacy drug UM policies above will be available online or on hard copy:
Effective July 1, 2017:
Medica to revise UM policies for medical pharmacy drugs
Medica will soon revise the following medical pharmacy drug utilization management (UM) policies, effective with July 1, 2017, dates of service. The following medications previously assigned a code are being updated to reflect a new code. These UM changes will apply to relevant prior authorization and pre-payment claims edit policies.
Medical pharmacy drug UM policies — Revised
| Drug code |
Drug brand name |
Drug generic name |
Change |
| J3590 |
Cuvitru |
immune globulin |
Addition of Cuvitro to subcutaneous immune globulin policy |
| J3590 |
Stelara
|
ustekinumab |
Addition of Stelara IV |
These policies will apply to Medica commercial, Minnesota Health Care Programs (MHCP) and individual and family business (IFB) members, but not to Medica Medicare members. All of these policies will be subject to pre-payment claims edits as well.
The new medical pharmacy drug UM policies above will be available online or on hard copy:
Reminder:
New policy addresses new-to-market medical benefit drugs
As previously noted, Medica is implementing a process to review and determine appropriate coverage or utilization management (UM) drug policies for medical benefit drugs and biologics that are new to market. As part of this process, Medica has added a new drug coverage policy stating that all new-to-market medical pharmacy products are not covered until completion of this review process.
Medica will not cover new-to-market professionally administered medical pharmacy products until they are reviewed and approved for coverage. Professionally administered medical pharmacy products are those administered under a member's medical benefit and administered to patients using a method such as:
- Intravenous infusion or injection
- Intrathecal infusion or injection
- Intramuscular injection
- Intraocular injection
"New to market" means up to six months from the date of final approval by the U.S. Food and Drug Administration (FDA). Medica will conduct its clinical review for each new medical pharmacy product within six months of final FDA approval, including a review of clinical data and patient safety information, and then make a coverage determination.
The new drug coverage policy noted above is available online. See Medica's drug management policies or call the Medica Provider Literature Request Line.
Medica published more about this change in a recent Provider Alert at the end of March 2017.
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Network News
Effective July 1, 2017:
Medica to update Medicare physician fee schedule
Beginning with July 1, 2017, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided.
Details on Medicare changes to drug fees are available online from CMS. Providers who have further questions may contact their Medica contract manager.
Fourth-quarter PCR checks to be mailed in April 2017
By the end of April 2017, Medica plans to mail to eligible providers the physician contingency reserve (PCR) payment for the fourth quarter of 2016. This represents a 100-percent return of the fourth-quarter 2016 PCR withhold, plus interest, for the Medica Prime Solution® Medicare product. Checks will cover PCR withheld for claims with dates of service of October 1, 2016, through December 31, 2016, and dates paid of October 1, 2016, through March 31, 2017.
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Administrative News
Effective April 4, 2017:
Medica revises reimbursement policies
Medica has updated the reimbursement policies indicated below, effective on or after April 4, 2017, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replaced all previous versions.
| Name |
| Add-On (updated code list) |
| Bilateral Procedures (updated code list) |
| Supply (updated code lists) |
| Time Span Codes (updated code list) |
These revised policies are available online or on hard copy:
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SelectCare/LaborCare News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (April 2017). Highlights that may be of interest to LaborCare®network providers include:
- Prior authorization no longer required for preferred formulary medications used to treat opioid dependence — now effective
- Prior authorization required for Spinraza — now effective
- New prior authorization requirement for levoleucovorin — scheduled for July 2017
- New Emergency Department Facility Evaluation and Management (E/M) Coding Reimbursement Policy — scheduled for July 2017
View the April 2017 UHC provider bulletin.
Reminder:
EBSO utilizes Renalogic for SelectCare dialysis claims
As a reminder to Medica SelectCareSM providers, EBSO, Inc., utilizes a dialysis cost containment program managed by Renalogic for dialysis-related services provided to SelectCare enrollees. Providers who have questions about this can call EBSO at 1-800-558-7798.
Providers can also access EBSO policies through the EBSO website, where additional provider-focused content is available including claim status, patient eligibility and benefit plan information. Refer to the EBSO website.
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