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Policies and Guidelines

UM and Prior Authorization

A utilization management (UM) policy is a document containing clinical criteria used by Medica staff members for prior authorization, appropriateness of care determination and coverage. The criteria are specific to the clinical characteristics of the population that will benefit from the treatment or technology. The needs of individual patients who may not meet these criteria must be considered and are addressed by the process in the section labeled "Coverage Issues" on the UM policy.

These policies provide general information concerning our administrative processes. The service may or may not be covered by all Medica plans. Please refer to the member’s plan document for specific coverage information. If there is a difference between this general information and the member’s plan document, the member’s plan document will be used to determine coverage. With respect to Medicare, Medicaid and MinnesotaCare members, these policies will apply unless these programs require different coverage.

Medica may use tools developed by third parties, such as MCG Care Guidelines®, to assist in administering health benefits.  

Medica UM policies and MCG Care Guidelines are not intended to be used without the independent clinical judgment of a qualified health care provider taking into account the individual circumstances of each member’s case. Medica UM policies and MCG Care Guidelines do not constitute the practice of medicine or medical advice. The treating health care providers are solely responsible for diagnosis, treatment, and medical advice.

Medica medical policies are a clinical reference that includes UM policies, coverage policies, drug management policies, Institute for Clinical Systems Improvement (ICSI) guidelines, Medica clinical guidelines, and MCG Care Guidelines (if applicable). Both the coverage policy and UM policy sections should be checked to determine coverage for a particular service.

For medical services that require prior authorization, as specified in the Prior Authorization List, see additional details below.

Medica requires that providers obtain prior authorization before rendering services. 

Beginning with January 1, 2014 dates of service, if any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. The provider will have 60 days from the date of the claim denial to appeal and supply supporting documentation required to determine medical necessity.

Medica reserves the right to conduct a medical necessity review at the time the claim is received.

Access the Claim Appeal Request Form »

Policies & Prior Authorization

Important Note: Before using these policies, please read the UM Policy Usage Notice.

Utilization Management Policies

Behavioral Health

Devices/Equipment

Diagnostics

Drugs

Home Care

Inpatient

Medical/Surgical Treatments

Surgical Procedures

Transplants - Organ & Bone Marrow

Note: The asterisk (*) Includes Medica DUAL Solution (MSHO)

Prior Authorization

Prior Authorization

The purpose of prior authorization is to evaluate the appropriateness of a medical service based on criteria, medical necessity, and benefit coverage. Please review the current Prior Authorization List of medical services that require prior authorization. For certain services, providers are encouraged to submit a prior authorization form that outlines information important in helping Medica determine the appropriateness of care for Medica members seeking related services. 

View full Prior Authorization list »

Devices, Diagnostics and Procedures Request Form

The full Prior Authorization List outlines all medical services requiring prior authorization from Medica. The following form is to be used as the preferred method for requesting prior authorization for these particular services. For pharmacy prior authorizations, see Drug Management Policies ».

View and print the Transplant Prior Authorization and Notification Form »
View and print the Prior Authorization Request Form »
View and print the Prior Authorization Request Form for Genetic Testing »
View and print the Prior Authorization Request Form for Home Health Agency (formerly Home Health Care) »
View and print the Prior Authorization Request Form for Out of Network Provider »
View and print the Prior Authorization Request Form for Spine Surgeries »
View and print the Prior Authorization Request Form for Wheelchair and Accessory »
View and print the Home Care Nursing (HCN) Hardship Waiver Application Form »
View and print the Home Care Nursing (HCN) Hardship Waiver Application Instructions »
View and print the Home Care Nursing (HCN) Hardship Waiver Policy »

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