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Medica Administrative Manual  > Policies and Procedures > Reporting Obligations

Reporting Obligations

The forms and processes below are intended for Medica network providers to use in responding to reporting obligations required by law, contract or accreditation standards (including those required by the National Committee for Quality Assurance, or NCQA®).

These forms and processes do not necessarily constitute an all-inclusive list of reporting obligations. However, we want providers to be aware of some important items.

Top Requirements

The Minnesota Department of Human Services (DHS) requires Medica to ensure that its network providers meet certain obligations pertaining to disclosure of ownership interests and the provision of items and services by individuals or entities excluded from participation in government programs. These requirements are summarized below, along with the process for submitting this information to Medica on a new Disclosure Statement form.

Disclosure of Ownership Interests

On an annual basis, providers must report to Medica the following information related to ownership interests:

  • The name and address of each person with an ownership or control interest in the provider, or in any subcontractor in which the provider has a direct or indirect ownership of 5 percent or more;
  • A statement as to whether any person with an ownership or control interest is related as a spouse, parent, child, or sibling to any other person with an ownership or control interest; and
  • For a person with an ownership or control interest in the provider, the name of any organization in which the person has an additional ownership or control interest.

Note: Providers must complete and submit the Disclosure Statement form on an annual basis, whether or not they have information to report. A New Disclosure Statement must be submitted when any information in the original statement has changed.

Disclosure Statement form (PDF)

This disclosure stems from requirements by the Centers for Medicare and Medicaid Services (CMS).

Additional requirements for disclosure

Disclosure of Excluded Individuals, Entities

Providers are required to follow these steps:

  1. Search the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE) database and the General Services Administration (GSA) Excluded Parties List System (EPLS) on a monthly basis to ensure that providers, agents, persons with an ownership or control interest, and managing employees (general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operations of an institution, organization or agency): (i) are not debarred, suspended or otherwise excluded from participation in Medicaid, Medicare, or any other federally funded government program; (ii) have not been convicted of a criminal offense related to that person’s or entity’s involvement in any federally funded government program; and (iii) have not been sanctioned by the OIG;
  2. Assure Medica that Provider will not employ, purchase products or services from, or contract with any subcontractor who: (i) has been convicted of a criminal offense related to the individual’s or entity’s involvement in any federally funded government program; (ii) is listed as debarred, suspended or otherwise excluded from participation in any federally funded government program; or (iii) has been sanctioned by the OIG; and
  3. Report to Medica within five days any information regarding individuals or entities who have been: (i) convicted of a criminal offense related to the involvement in any federally funded government program; (ii) listed as debarred, suspended or otherwise excluded from participation in any federally funded government program; or (iii) sanctioned by the OIG.

From the U.S. Department of Health and Human Services, and the U.S. General Services Administration, providers are able to access:

Providers can submit this information to Medica using a new Disclosure Statement form.
Disclosure statement form (PDF)

Return Your Required Forms

There are two ways to return forms to Medica.

  • Scan the completed and signed form and e-mail it to ProviderCertifications@medica.com
  • Mail the form to:
  • Medica
    Mail Route CP425
    P.O. Box 9310
    Minneapolis, MN 55440-9310

The state of Minnesota requires providers to report all quality complaints received at the clinic level to the enrollee's health plan. (Minnesota Statute 62D.123, Subd. 2 and Minnesota Rules 4685.1110 Subp.9) Complaints directed to the medical group are to be investigated and resolved by the medical group. Providers will also cooperate with Medica to resolve such complaints from members. Quality complaints are defined as concerns regarding access to services, communication/behavior, coordination of care, technical competence, and appropriateness of services affecting patient safety or comfort.

Medical groups must provide a written report to the Medica Quality Improvement Department on a quarterly basis. Please submit by the second Friday following the end of each quarter. Reporting is required even if no complaints are received during the quarter. Please see the Member Complaints section of your provider agreement, as well as the process and form at the links below.

Complaint Review Process
Quality Complaint Reporting form (PDF)



REV 6/2021

Learn more about rural health clinics and federally qualified health centers or submit to Medica a notification of rate change related to these entities:

Medica providers in all states are required to notify Medica immediately whenever a serious reportable event, also known as an adverse health event or “never event,” happens to a Medica member. The Serious Reportable Events policy describes reporting requirements and processes.

Serious Reportable Events policy (PDF)
Serious Reportable Events Identification Form (PDF)

In addition, Minnesota Statute 144.7065 requires Minnesota hospitals, freestanding outpatient surgical centers and regional treatment centers to report specific adverse health events to the Minnesota Department of Health (MDH). A complete list of reportable events can be found on the MDH website.

Further information about Minnesota state reporting requirements can be found in the Adverse Health Events section on the MDH website.



REV 6/2021

If a Medica network provider refuses to continue providing health care services to a member, the provider must notify Medica of his/her intention to discontinue treating the member. For more information on the provider refusal of care process, providers should reference Termination of Health Services by a Provider.

Termination of Health Services by a Provider



REV 6/2021

Date: 6/14/2021 7:26:34 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01