December 2013

General Information2013 'Raising the Bar' innovation award winners announcedMedica to implement change to prior authorization processMedica enhances Focus product, network2014 Patient Choice Insights tiers to take effect January 1Cost information on Main Street Medica to be updatedMedica to make benefit changes for hospital-based clinicsMedica Spine Care program provides value for its membersMedica to end Medicalis TDS contract for high-tech imagingMedica Foundation announces provider grant recipientsText-only descriptions to display for Premium designationsAnnual Medica compliance training required by year-end

Clinical InformationMedica to implement new coverage policy, eff. Jan. 1Medica to make coverage policy change, eff. Jan. 1Medica to update UM policies relative to MCG Care GuidelinesMedical policies and clinical guidelines to be updated

Pharmacy InformationMedica to update commercial, Marketplace, MHCP formulariesMedica to update drug management policies, eff. Jan. 1Medica requires PA for Suboxone use by MHCP members

Network InformationMedica to revise fee schedule for MHCP productsMedica to update Medicare physician fee schedule

Administrative InformationProvider College administrative training topic for Nov.-Dec.Credentialing voicemail to be discontinuedCredentialing adds 2 new provider specialty designationsMedica to make credentialing application process change

Medica Connections - December 2013

Amendments to no longer be sent for demographic changesMinnesota providers need to submit claims electronicallyProviders can sign up for EFT, ERAs for new payer IDICD-10 codes to be required for claims as of October 1, 2014Medica revises reimbursement policy, eff. Oct. 13Medica to revise reimbursement policy, eff. Dec. 1Medica to revise reimbursement policy, eff. Jan. 1Medica to revise claims processing for new patient visitsUpdates to Medica Provider Administrative Manual

PPO InformationAetna changes its claim-escalation processLatest Aetna provider bulletin available online

GENERAL INFORMATION

2013 'Raising the Bar' innovation award winners announced

Medica is pleased to announce the winners of its sixth-annual "Raising the Bar" innovation awards forproviders. Award winners received $25,000 and an award plaque to recognize their achievement. With"Raising the Bar: Expanding Unconventional Care Collaborations to Improve Patient Health" this year,Medica highlights the work of groups involved in unique care collaborations with new care partners inthe community. The following providers are this year's winners for this innovation award from Medica.

Catholic Charities of St. Paul & Minneapolis, a nonprofit community organization striving toend poverty and homelessness in the TwinCities, initiated a transitional recovery-care pilotprogram with North Memorial Health Care andHennepin County. Its purpose was to provide asafe, dignified recovery space for homelesspatients after discharge from the hospital. Itsaims were to prevent patients from returning tohomelessness and to reduce ER visits and re-hospitalization. The pilot provided patientsrespite in a stable, private setting with servicesat hand for ongoing continuity of care. As anoutcome, North Memorial saw a dramatic dropin both ER and hospital admissions (52% and67% decreases, respectively), resulting innearly $500,000 in savings in less than 1 year.Courage Kenny Rehabilitation Institute,formerly Courage Center, based in GoldenValley, Minn., is a facility for inpatient and

outpatient medical rehabilitation services. The

Medica Connections - December 2013

center partnered with the MinnesotaDepartment of Human Services (DHS) tocreate a disability-competent primary careclinic (PCC) for its patients with disabilities andcomplex conditions, including a telemedicinecomponent to treat patients in their homes. Asoutcomes, the Courage Center PCC modeldemonstrated a 67% decrease in hospital daysoverall, a 62% decrease in the 30-day hospitalreadmission rate, and ultimately savings to thestate Medicaid program of nearly $2.5 millionannually due to reduced hospitalizations andER visits.

With its "Raising the Bar" innovation awards, Medica seeks to recognize the work of provider groups___ from single-site practices to healthcare systems ___ that are undergoing unique changes toimprove patient care, with proven results. Medica established its provider innovation awards in 2008 torecognize the provider community's work in defining healthcare excellence.

Effective January 1, 2014:

Medica to implement change to prior authorization process

Beginning with January 1, 2014, dates of service, in order to provide better customer service to itsmembers, Medica will follow market peers and begin denying claims as provider liability for healthservices that require a prior authorization if no such prior authorization was granted. As a reminder,Medica provider network participation agreements require providers to follow Medica prior authorizationpolicies, which include utilization management (UM) policies. See a list of health services for whichMedica requires prior authorization.

Medica is also revising the provider appeal process to include a special category for claims denied dueto failure to obtain prior authorization. This new category includes a 60-day timeframe for submitting anappeal after the claims denial is issued.

Also as a reminder, claims that are denied as provider liability are not eligible to be billed to members.The only exception is in cases where the member has signed a pre-service payment consent formindicating that the member knows that the specific health services are not covered (or in this instance,not covered because prior authorization was either not sought or not granted), and that the memberagrees to assume financial liability for such specific health services.

Refer to the Provider Administrative Manual for more on prior authorization policies andprocedures.Refer to the Provider Administrative Manual for more on health management related tobenefit appeals.

Medica Connections - December 2013

See the updated Claim Appeal Request Form.

Medica enhances Focus product, network

Medica is expanding the Medica Focus® network to include 15 counties in and near the Twin Citiesmetropolitan area, and has made some important changes to the product. Medica members are nolonger required to select a home clinic, and newly issued cards do not list a clinic name or clinic ID.Members continue to have open access and do not need referrals within the Focus network. The updatedMedica Focus provider network includes 24 hospitals and more than 200 clinics.

Here is a sample Medica Focus member ID card.

Medica Focus continues to provide Medica members with a limited-network option. Due to a significantout-of-network out-of-pocket impact for these patients, physicians in the Medica Focus network arestrongly encouraged to admit to in-network hospitals and recommend in-network specialty providers

(plus, remind patients to verify that specialists are in the Focus network). Many Medica Choice®

network specialists are included in the Focus specialty network. For the most up-to-date list ofproviders in the Focus network, see the provider directory on medica.com.

Claims from Medica Focus providers continue to be paid at Medica Focus contracted rates, while allout-of-network providers are reimbursed at the Medica Focus out-of-network rate. The productcontinues to be offered to large fully and self-funded employer groups in Minnesota, as well as to smallemployers outside the Minnesota healthcare exchange, MNsure.

For more details on this product, see the fact sheet for Medica Focus.

2014 Patient Choice Insights tiers to take effect January 1

Medica Connections - December 2013

Each year, Patient Choice reviews tier assignments for providers who participate in the Patient Choice

InsightsSM by Medica network. The 2014 tiers have been set and participating providers should havereceived a letter indicating their tier assignment for next year.

Affected providers should begin using their 2014 tier assignment beginning January 1, 2014, whenseeing patients who are enrolled in plans that utilize the Medica Insights network. This network isarranged into three tiers, based on provider performance on various cost and quality measures.Depending on the type of services delivered, the tiers can affect member benefits. Generally, the lowerthe tier, the lower the member's copayment and/or percentage of coinsurance.

Providers can look up their 2014 tier in the provider directory on medica.com.

Cost information on Main Street Medica to be updated

Medica will be updating the cost information for imaging services and durable medical equipment on itsMain Street Medica website. The updates will occur in early January 2014.

For seven years, Medica has been making pricing information available to its members online. As partof the update process, Medica conducts a review of recent claims to determine the conditions,diseases and procedures to be included. These services are then analyzed to determine the cost

information based on current contracts for the Medica Choice® provider network. The results willcontinue to be displayed for organizations using average cost ranges for a particular supply, condition,disease or procedure.

Providers who have any questions about the information on Main Street Medica, or would like toreceive a copy of a report for their organization, are welcome to contact their contract manager.

Effective January 1, 2014:

Medica to make benefit changes for hospital-based clinics

Medica is making Medicare product coverage changes related to hospital-based or "provider-based"

clinics for 2014. This change, which applies to Medica Prime Solution® and Medica Clear Solution®

plans, involves a new copayment tier for these Medicare plans that have a copayment due for officevisits. This new higher-copay tier will apply instead of either the office visit copay or the outpatientcopay when members see providers in the hospital-based clinic setting. This benefit change will beeffective with January 1, 2014, dates of service for affected members.

The principle behind this copayment addition is that it removes the surprise that Medicare members

Medica Connections - December 2013

previously had in getting a higher cost share of the outpatient charges, yet still reflects that costs andrelated billing remain higher for these visits based on their hospital setting.

Medica Spine Care program provides value for its members

The Medica Spine Care program is intended to increase quality and efficiency for members with healthissues related to the spine, such as low-back pain. The Medica Spine Care program aims to:

Promote conservative care first for membersImprove members' understanding of their health condition and treatment optionsIncrease members' confidence in their treatment decisionsEnhance communication between members and their health care provider or providers

Having a treatment decision support (TDS) health coach involved for support can help membersnavigate the treatment decision process with a goal of finding the right care for them at the right placeand time.

The program, which launched in spring 2013, has already added value for Medica members. In onesituation, the participating member noted that this program made him more active and involved inworking with both his orthopedist and physical therapist to better understand his back problem. As aresult, he learned to deal with his back pain, learned to accept it, and learned how to care for his backon a daily basis. After evaluating treatment options with the help of his health coach, he saw how heneeds to work on strengthening his back and to increase his awareness to care for his back.

Learn more about the Medica coaching program.

(Update to "Medica Spine Care program undertakes member education" article in the July 2013 edition of Medica Connections. See

July 2013 edition.)

Medica to end Medicalis TDS contract for high-tech imaging

As of February 2014, Medica will discontinue its relationship with Medicalis as a vendor partner fortreatment decision support (TDS) related to the Medica high-tech imaging program. Providers who useMedicalis TDS through Medica currently will need to seek another TDS option.

Providers who had an Access Agreement to use Medicalis through Medica (those who will see a directimpact from the upcoming change) have been notified by mail and are encouraged to select a new TDSoption in the coming months. For a direct contract with Medicalis, providers may visit medicalis.comor call 1 (877) 579-5454.

Medica Connections - December 2013

Also in February 2014, Medica will be discontinuing its partnership with Nuance through the Institute for ClinicalSystems Improvement (ICSI) collaborative for high-tech imaging TDS services.

As a reminder, although ordering physicians are still encouraged to complete TDS for high-techimaging services, Medica no longer requires the TDS step, and there is no impact on related claims.

Medica Foundation announces provider grant recipients First-round 2013 behavioral health grants total $400,000

The Medica Foundation has concluded its behavioral health round of grant-making in 2013, awardingprogram grants totaling $400,000 to 8 nonprofit agencies. Program grants were awarded to severalprovider groups and healthcare foundations:

Center for Victims of Torture (Minneapolis) __ to pilot a new treatment model that adds mentalhealth and targeted case management services to the medical care offered at a primary careclinic

The Family Partnership (Minneapolis) __ to pilot narrative exposure therapy for individuals fromaffected culturally diverse communities with post-traumatic stress disorder

Northeast Youth and Family Services (St. Paul) __ to provide a year-round out-of-school daytreatment program that will provide therapy and development programming for youth with amental illness as well as provide family therapy and education for their families

Comunidades Latinas Unidas En Servicio (St. Paul) __ to expand a domestic violence programto support the mental health needs of children who have witnessed domestic violence

HealthEast Foundation (St. Paul) __ to provide cohorts who have completed treatment with aneight-week-long alternative-care recovery program

Hennepin County (Minneapolis) __ to add a certified peer specialist to the staff as it expands todouble the number of clients served

National Alliance for the Mentally Ill - Minnesota (St. Paul) __ to educate mental health andhealthcare providers, people living with mental illnesses and their families on effective ways tohelp people with mental illnesses to quit smoking

This cycle of grant-making focused on programs that develop capabilities or change processes relatedto the continuum of behavioral healthcare service interventions, accessibility and sustainability.

Details about grant recipients, funding opportunities, giving guidelines and application deadlines areavailable online at medicafoundation.org. Information on Medica Foundation funding priorities andgrant application periods for 2014 will be available early next year.

Medica Connections - December 2013

Text-only descriptions to display for Premium designations

Medica is now preparing for the 2014 Premium Designation program. There will be a change to howdesignations are displayed for individual physicians in the Medica online provider directories. Thecurrent system uses two, one or zero stars to convey quality and cost-efficiency designations forphysicians. Beginning in January 2014, there will be text-only displays.

Designation result Current display January 2014 displayQuality & Cost Efficiency «« Quality & Cost Efficiency

Quality & Not Enough Data toAssess Cost Efficiency

«

Not Enough Data to AssessCost Efficiency

Quality & Not Enough Data toAssess Cost Efficiency

Quality & Did Not Meet CostEfficiency

« Quality & Did Not Meet CostEfficiency

Not Enough Data to Assess Not Enough Data to Assess Not Enough Data to Assess

Not Evaluated Not Evaluated Not Evaluated

Did Not Meet Quality & CostEfficiency

(blank) Did Not Meet Quality & CostEfficiency

Based on consumer and physician research, it was determined that the display of stars implied arelative rating scale rather than a designation value. To improve clarity and increase transparency, theprogram will be using text that more clearly communicates designation results.

In addition to the text-only change above, a "Tier 1" symbol will be displayed for physicians with theQuality & Cost Efficiency designation:

This change is intended for easy-to-find results when Medica members are searching for a physicianin the online provider directory, to make it easier for them to find doctors who have been recognizedwith this designation.

Due December 31, 2013:

Annual Medica compliance training required by year-end

As a reminder, the Centers for Medicare and Medicaid Services (CMS) requires that Medicareproviders complete annual compliance training. The training requirement applies to all organizationsthat provide healthcare services or administrative services for Medicare-eligible individuals under theMedicare Advantage or Medicare Part D program. This compliance training is required by December 31each year.

Medica Connections - December 2013

Learn more and complete the compliance training.

CLINICAL INFORMATION

Effective January 1, 2014:

Medica to implement new coverage policy

The following benefit determination will be effective beginning with January 1, 2014, dates of service.This new policy will apply to all Medica products including government products unless a particularhealth plan (whether commercial, Medicare or Medicaid) requires different coverage.

Clinical trial participationOn January 1, 2014, revisions in the Patient Protection and Affordable Care Act will mandate that agroup health plan or a health insurance issuer offering coverage may not deny individual participation,discriminate against an individual on the basis of participation, or deny coverage of routine patientcosts for items and services rendered in a clinical trial.

In accordance with the provisions outlined in this upcoming mandate, Medica will cover routine patientcosts for participation in an approved clinical trial when:

The items or services would be a covered benefit if not provided in connection with an approvedclinical trial; andThe approved clinical trial is a phase I, phase II, phase III, or phase IV clinical trial that isconducted in relation to the prevention, detection, or treatment of cancer or other life-threateningcondition. A life-threatening condition is defined as any disease or condition from which thelikelihood of death is probable unless the course of the disease or condition is interrupted; andThe individual meets the criteria defined in the trial protocol with respect to treatment of canceror other life-threatening condition.

Items and services that continue to not be covered include:

The investigational item, device, service, or drugItems and services that are provided solely to satisfy data collection and analysis needs and arenot used in direct clinical management of the memberA service that is clearly inconsistent with widely accepted and established standards of care fora particular diagnosisTravel, room and board, and related expensesItems and services otherwise excluded from coverage under the member's coverage document

On January 1, 2014, Medica will implement coverage policy "Clinical Trial Participation" and retireutilization management policy "Cancer Clinical Trial Participation, Coverage of Routine Supplies andServices." Prior authorization of services will no longer be required.

The complete text of the policy that applies to this determination will be available online or on hard

Medica Connections - December 2013

copy:

See coverage policies at medica.com as of January 1, 2014; orCall 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 January 1, 2014:

Medica to make coverage policy change

The following benefit determination will be effective beginning with January 1, 2014, dates of service.This change will apply to all Medica products including government products unless a particular healthplan (whether commercial, Medicare or Medicaid) requires different coverage.

Extracorporeal shock wave therapyMedica has reviewed extracorporeal shock wave therapy (ESWT) for musculoskeletal indications andsoft tissue injuries, including radial ESWT, and has determined that this technology is investigative andtherefore not covered.

ESWT is a non-invasive treatment suggested for acute or chronic muscle pain, tendinopathies, andother indications (e.g., plantar fasciitis/heel pain syndrome; musculoskeletal disorders of the shoulder,elbow, patella, or hip, wound therapy, stress/delayed/non-union fractures). Two types of ESWT devicesare currently being used: focused and radial. Focused ESWT generates shock waves designed toconverge on a focal point within the body, where the wave imparts its maximum strength. RadialESWT, a newer application of wave therapy, generates pressure waves that reach maximum strengthwithin the generator, producing a less intense effect on the targeted tissue.

The policy title will be changed from "Extracorporeal Shock Wave Treatment for MusculoskeletalIndications and Soft Tissue Injuries" to "Extracorporeal Shock Wave Therapy (ESWT) forMusculoskeletal Indications and Soft Tissue Injuries."

The complete text of the policy that applies to this determination will be available online or on hardcopy:

See coverage policies at medica.com as of January 1, 2014; orCall the Medica Provider Literature Request Line for printed copies of documents.

Effective January 1, 2014:

Medica to update UM policies relative to MCG Care Guidelines

As previously published, Medica may use tools developed by third parties, such as MCG Care®

Medica Connections - December 2013

Guidelines , to assist in administering health benefits. This use of MCG Care Guidelines by Medicawill be effective with January 1, 2014, dates of service, and is limited to specific Medica individual andfamily business (IFB) members who are identifiable with group/policy number "IFB."

The following utilization management (UM) policies will be updated to include a reference to the MCGCare Guidelines.

UM policies __ RevisedThese versions will replace all previous versions.

Name Policy numberBone Growth Stimulators III-DEV.07

Microprocessor Controlled Knee Prostheses, With or Without Polycentric,Three-Dimensional Endoskeletal Hip Joint System

III-DEV.17

Implantable Deep Brain Stimulation III-DEV.19

High Frequency Chest Wall Compression (HFCWC) Devices III-DEV.20

Vacuum-Assisted Negative Pressure Wound Therapy III-DEV.21

Sacral Nerve Stimulation (SNS) III-DEV.22

Coronary Artery Calcium Scoring (CACS) III-DIA.03

Genetic Testing for Hereditary Breast and / or Ovarian Cancer (BRCA 1

And BRCA 2 Genes And BRACAnalysis® Rearrangement Test [BART])

III-DIA.04

Genetic Testing for Cardiac Channelopathies III-DIA.05

Genetic Testing for Susceptibility to Colorectal Cancer (CRC) Syndromes III-DIA.06

Genetic Testing for Cardiomyopathies III-DIA.07

Comparative Genomic Hybridization (CGH) Microarray Testing forNeurodevelopmental Chromosomal Imbalances

III-DIA.09

Skilled Nursing Facility III-INP.03

Proton Beam Radiation Therapy III-MED.06

Rhinoplasty Procedure With or Without Septoplasty III-SUR.04

Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive SleepApnea/Hypopnea Syndrome

III-SUR.08

Abdominoplasty/Panniculectomy III-SUR.13

Thoracic Sympathectomy for Primary Hyperhidrosis III-SUR.25

Varicose Vein and Venous Insufficiency Treatments: IncludingLigation/Stripping, Phlebectomy, Endovenous Radiofrequency Ablation,Endovenous Laser Ablation, Sclerotherapy Procedures

III-SUR.26

Female Breast Reduction Surgery - Reduction Mammoplasty III-SUR.27

Reconstructive Blepharoplasty (Upper or Lower Eyelid), BlepharoptosisRepair (Upper Eyelid) and Brow Lift

III-SUR.29

Gastrointestinal Surgery for Morbid Obesity III-SUR.30

Male Gynecomastia Surgery III-SUR.31

Lumbar Spine Surgeries III-SUR.34

Autologous Cultured Chondrocyte (CarticelTM) Transplantation for the Knee III-SUR.35

Cervical Spine Surgeries III-SUR.37

Liver Transplantation III-TRA.02

Kidney Transplantation III-TRA.03

Medica Connections - December 2013

Lung Transplantation (Single or Double) III-TRA.11

Heart Transplantation (Adult And Pediatric) III-TRA.12

Drug UM (prior authorization) policies __ RevisedThese versions will replace all previous versions.

Name Policy number

Abatacept (Orencia®) III-DRU.12

Bevacizumab (Avastin®) III-DRU.10

Cetuximab (Erbitux®) III.DRU.22

Eculizumab (Soliris®) III-DRU.24

Icatibant (Firazyr®) III-DRU.27

Immune Globulin (intravenous, subcutaneous) III-DRU.18

Sipuleucel-T (Provenge®) III-DRU.25

Tocilzumab (Actemra®) III.DRU.26

Ustekinumab (Stelara®) III-DRU.08

These updated documents will be available online or on hard copy:

View UM policies at medica.com of January 1, 2014; orCall the Medica Provider Service Center at 1-800-458-5512 for printed copies of documents orfor more information.

Medica UM policies and MCG Care Guidelines are not intended to be used without the independentclinical judgment of a qualified healthcare provider taking into account the individual circumstances ofeach member's case. Medica UM policies and MCG Care Guidelines do not constitute the practice ofmedicine or medical advice. The treating healthcare providers are solely responsible for diagnosis,treatment, and medical advice.

(Update to "MCG Care Guidelines to supplement policies for IFB members" article in the November 2013 edition of Medica

Connections. See November 2013 edition.)

Effective January 1, 2014:

Medical policies and clinical guidelines to be updated

Medica will soon update one or more utilization management (UM) policies, coverage policies, Institutefor Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below.These policies will be effective January 1, 2014, unless otherwise noted.

Coverage policies __ New Name

Medica Connections - December 2013

Clinical Trial Participation

Coverage policies __ RevisedThese versions will replace all previous versions.

NameBone Anchored Hearing Aid (BAHA)

Breast Magnetic Resonance Imaging (MRI)

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications and Soft TissueInjuries (Formerly Extracorporeal Shock Wave Treatment for Musculoskeletal Indications and SoftTissue Injuries)

Gene Expression Profiling for Assessing Cancers of Unknown Origin

Lovaas Therapy/Intensive Early Intervention Behavior Therapy Services (IEIBTS)/Intensive BehaviorIntervention (IBI)

Percutaneous Neuromodulation Therapy (PNT) for the Treatment of Pain

Vision Therapy

UM policies __ InactivatedName Policy numberCancer Clinical Trial Participation, Coverage of Routine Supplies andServices (Replaced by Coverage policy titled: Clinical Trial Participation)

III-MED.04

ICSI guidelines __ RevisedThese guidelines are available on medica.com.

NamePreventive Services for Adults (Released September 2013)

Preventive Services for Children and Adolescents (Released September 2013)

Adult Depression in Primary Care (Formerly Major Depression in Adults in Primary Care)(Released September 2013)

These documents will be available online or on hard copy:View medical policies and clinical guidelines at medica.com as of January 1, 2014; orCall the Medica Provider Literature Request Line for printed copies of documents.

PHARMACY INFORMATION

Effective January 1, 2014:

Medica to update commercial, Marketplace, MHCP formularies

Medica Connections - December 2013

Medica has reviewed the following products, with their respective coverage status to be effectiveJanuary 1, 2014. As indicated in the table below, these changes will apply to the Medica standardcommercial drug formulary; the new Marketplace drug formulary for individual and family business(IFB) members and small group plan members who purchase health plans on state exchanges; andthe Medica Minnesota Health Care Programs (MHCP) drug formulary. The Medica MHCP formulary

applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus

program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic

Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, orMSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.

Genericname (brandname)

CommercialandMarketplaceformularystatus

MedicaMHCPformularystatus

Currentpreferredalternatives

Restrictionsandcomments

Approvedtherapeuticindications

certolizumabpegol

(Cimzia®)

CommercialSpecialty tier2;Marketplacetier 6

Non-formulary

Enbrel,Humira

Priorauthorization;specialty drug

Currentutilizers will begrandfatheredat Specialtytier 1/FormularySpecialtycopay

Treatment ofCrohn'sdisease,rheumatoidarthritis, andpsoriatic arthritis

etanercept

(Enbrel®)

CommercialSpecialty tier1;Marketplacetier 5

FormularySpecialty

Priorauthorization;specialty drug

Treatment ofrheumatoidarthritis,psoriaticarthritis, juvenileidiopathicarthritis,ankylosingspondylitis, andplaque psoriasis

ustekinumab

(Stelara®)

CommercialSpecialty tier2;Marketplacetier 6

Non-formulary

Enbrel,Humira

Priorauthorization;specialty drug

Currentutilizers will begrandfatheredat Specialtytier 1/

Treatment ofplaque psoriasis

Medica Connections - December 2013

FormularySpecialtycopay

levothyroxine

(Levothroid®,

Levoxyl®)

Commercialtier 3;Marketplacetier 3

Non-formulary

levothyroxine Currentutilizers will begrandfatheredat tier 2 copay

Treatment ofhypothyroidism

oxybutynintransdermalsystem

(Oxytrol®)

Commercial -excluded;Marketplace -excluded

Non-formulary

oxybutynin(oral),tolterodine,Detrol LA,trospium

This product isnow availableover thecounter

Treatment ofoveractivebladder

Medica drug formularies are available online or on paper:View Medica drug formularies on medica.com.To request a printed copy, providers may call the Medica Provider Literature Request Line.

Medication request formsA uniform formulary exception request form should be used when requesting a formulary exception. Itis important to fill out the form as completely as possible and to cite which medications have been triedand failed. This includes the dosages used and the identified reason for failure (e.g., side effects orlack of efficacy). The more complete the information provided, the quicker the review, with lesslikelihood of Medica needing to request more information. To request formulary exceptions, providerscan:

Download an exception form at medica.com.Call MedImpact at 1-800-788-2949.

Effective January 1, 2014:

Medica to update drug management policies

Medica will soon update the following drug utilization management (UM) policies effective with January1, 2014, dates of service.

Drug UM (prior authorization) policies __ RevisedThese versions will replace all previous versions.

Name

Actemra® (tocilizumab)

Amevive® (alfecept)

Cimzia® (certolizumab)

Enbrel® (etanercept)

Erbitux® (cetuximab)

Medica Connections - December 2013

Humira® (adalimumab)

Kineret® (anakinra)

Orencia® (abatacept)

Provenge® (sipuleucel-T)

Simponi® (golimumab)

Stelara® (ustekinumab)

Xeljanz® (tofacitinib)

These documents will be available online or on hard copy:View drug coverage and UM policies at medica.com as of January 1, 2014; orCall the Medica Provider Literature Request Line for printed copies of documents.

Medica requires PA for Suboxone use by MHCP members

As a reminder, Medica requires prior authorization for Minnesota Health Care Programs (MHCP)

enrollees to use all formulations of Suboxone® (buprenorphine and naloxone), including Zubsolv. Thismedication is indicated for treatment of opioid dependence. Failure to receive prior authorization formedications like this can result in denial of related claims. Suboxone prior authorization is also requiredfor members whose benefit includes the Medica standard commercial drug formulary.

Medica drug formularies (with drug-specific requirements) are available both online and on hard copy:View formularies online at medica.com, orCall the Medica Provider Literature Request Line for a printed copy.

NETWORK INFORMATION

Effective January 1, 2014:

Medica to revise fee schedule for MHCP products

Effective January 1, 2014, Medica will implement a revised fee schedule for its enrollees in MinnesotaHealth Care Programs (MHCP), affecting the Medica Choice Care, Medica MinnesotaCare and MedicaAccessAbility Solution products. The revised Medica MHCP fee schedule will be based on the feeschedule used by the Minnesota Department of Human Services (DHS) to pay providers for services

Medica Connections - December 2013

provided to its fee-for-service enrollees. The effect on reimbursement overall for specific clinics willvary by specialty and the mix of services provided.

Providers who have further questions may contact their Medica contract manager.

Effective January 1, 2014:

Medica to update Medicare physician fee schedule

Beginning with January 1, 2014, dates of service, Medica will implement the quarterly update to itsMedicare physician fee schedule for applicable Medica products. This fee schedule change will reflectthe January 2014 Centers for Medicare and Medicaid Services (CMS) update applicable toreimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterlyupdate will vary based on specialty and mix of services provided. Updates for durable medicalequipment (DME) and orthotics and prosthetics (O&P) will not be implemented at this time.

Details on Medicare changes to drug fees are available online from CMS.

Providers who have further questions may contact their Medica contract manager.

ADMINISTRATIVE INFORMATION

Provider College administrative training topic for Nov.-Dec.

The Medica Provider College offers educational sessions on various administrativetopics. The following class is available by webinar for all Medica network providers, at no charge.

Training class topic"New Medica IFB Administrative Platform" (class code: IFBP)This webinar will introduce the new Medica individual and family business (IFB) administrative platformpilot to providers. It will cover details such as the new payer ID number, claim address, and appealinformation as well as information on clinical guidelines, pharmacy, chiropractic care and behavioralhealth. Available tools and resources will be discussed.

Class scheduleClass code Topic Date Time NotesIFBP-WN New Medica IFB Nov. 21 10-11 am Class code with "WN" means

Medica Connections - December 2013

Administrative Platform offered via webinar in Nov.

IFBP-WD New Medica IFBAdministrative Platform

Dec. 19 10-11 am Class code with "WD" meansoffered via webinar in Dec.

For webinar trainings, login information and class materials are e-mailed close to the class date. Toensure that training materials are received prior to a class, providers should sign up as soon aspossible.

The time reflected above allows for questions and group discussion. Session times may vary based onthe number of participants and depth of group involvement.

RegistrationThe registration deadline for all classes is one week prior to the class date. To register for the sessionlisted, providers may do either of the following:

Fill out the Provider College registration form (available online at medica.com under "Newsand Training") and e-mail it to providercollege@medica.com.Send an e-mail with the same details as listed on the registration form toprovidercollege@medica.com.

Effective December 2, 2013:

Credentialing voicemail to be discontinued

Effective on December 2, 2013, the Medica Credentialing department will no longer have voicemailavailable. Providers with questions will be directed to the Medica Credentialing e-mailbox instead.Providers who call the credentialing voicemail phone number as of December 2 will hear a messagestating that it is no longer in use and questions should go to the credentialing e-mail address atcredinforequest@medica.com. Providers without e-mail access may call the Medica Provider ServiceCenter at 1-800-458-5512 and have their call redirected to the Medica Credentialing department.

Credentialing adds 2 new provider specialty designations

Medica has recently added two new practitioner specialties available to identify practitioners as part oftheir provider demographics (for instance, available in provider directories for Medica members to use).The two new specialties are Medical Genetics and Sleep Medicine. If practitioners credentialed withMedica would like to change their specialty, and they qualify to change it by having the appropriatetraining and/or education, they may contact the Medica Credentialing department atcredinforequest@medica.com.

Medica Connections - December 2013

Effective January 1, 2014:

Medica to make credentialing application process change

Beginning January 1, 2014, the Medica Credentialing department will no longer process incompletecredentialing applications. All incomplete applications will be promptly returned to providers with anexplanation of what was missing. Resubmitted applications will be processed in the order received. Providerswho have questions about this process change can send an e-mail to credinforequest@medica.com .

Effective January 1, 2014:

Amendments to no longer be sent for demographic changes

Effective January 1, 2014, Medica will discontinue its process of sending amendments to providercontract documents due to demographic changes. This change means that the site list will no longerbe maintained as part of the paper contract documents, but will instead be maintained electronically.Providers or their delegated representatives can view and submit site level demographic changesunder the tax IDs that they manage.

Medica will continue to send amendments to provider contract documents for any changes to the nameor federal tax ID listed on the first and last page of the contract document, mergers or acquisitions, ratechanges, or other changes that require advance notification in accordance with the provisions outlinedin the provider contract document or the provider administrative manuals.

Medica will continue its annual data validation process, and providers are required to submit theirdemographic changes in advance of the site addition or termination, as outlined in the providercontract document. Furthermore, providers should use the Provider Demographic-Update Online Tool(PDOT) or the Add/Term/Change (ATC) Form to make changes on an ongoing basis as they occurthroughout the year in order to prevent claims-payment issues.

Making demographic-change requestsTo keep demographic details current with Medica, providers can use one of the following methods:

Use the secure provider login at medica.com and access PDOT.Make changes by submitting the ATC Form located on medica.com.

A password is required to access PDOT on medica.com. For more information about makingdemographic changes, providers may refer to the PDOT User Guide or call the Provider ServiceCenter at 1-800-458-5512. PDOT is accessible to primary or secondary administrators for a providergroup. More details about demographic updates are also available at medica.com.

Medica Connections - December 2013

Which data can be updated As a reminder, PDOT and the ATC form are used to change or correct clinic demographic data and

contract-level or site-level data for Medica, Medica SelectCareSM or Patient Choice plans. Thisincludes data such as:

A clinic or site for an existing contractAddressAdministrative or billing numberClinic nameFederal identificationCheck nameCheck addressClinic e-mail addressFax numberOffice days and hoursPatient appointment phone number

Note: Demographic updates including federal tax ID changes or check name or address changes alsoneed to be made as part of the Electronic Payments and Statements (EPS) electronic transaction aswell as the Medicalis high-tech imaging system, for those providers enrolled in these programs. ThePDOT, EPS and Medicalis systems are separate and need to be updated individually when suchchanges occur. These systems are available through the secure Electronic Transactions login page.

Reminder:

Minnesota providers need to submit claims electronically

As a reminder for Minnesota-based providers, healthcare claims need to be submitted electronically topayers. This applies for all medical claims. Claims submitted on paper can be rejected. Smallerproviders not currently using their own electronic data interchange (EDI) vendors or clearinghouses toprocess their claims may sign up to use the MN E-Connect claims submission service free of charge.Find out more from MN E-Connect.

Note: For Medica claims submission during the IFB administrative platform pilot, Emdeon WebConnect will be available for new Medica IFB payer ID #12422. This new IFB claims-submission resourcewill be intended for the same providers who use MN E-Connect, which is currently only available for Medicapayer ID #94265. Web Connect will similarly be available at no cost to providers. More details on signing up touse Web Connect are forthcoming.

Medica Connections - December 2013

Providers can sign up for EFT, ERAs for new payer ID

During the Medica pilot of its new administrative platform for individual and family business (IFB)claims, electronic payments and payment notices will be available for payer ID #12422. IFB memberswill be identifiable by the new group/policy number "IFB" on their ID cards. The following links are forproviders to directly enroll with Emdeon for electronic funds transfer (EFT) and electronic remittanceadvices (ERAs).

Providers new to Emdeon enrollment.Providers already enrolled with Emdeon for other payers.

(Update to "Claims-submission, payment details for new IFB platform" article in the November 2013 edition of Medica Connections.

See November 2013 edition.)

ICD-10 codes to be required for claims as of October 1, 2014

Medica continues to prepare for next year's ICD-10 coding transition and will follow the Centers forMedicare and Medicaid Services (CMS) guideline for code submission. As a result, ICD-9 codes willbe accepted from providers through September 30, 2014, dates of service, but all providers mustsubmit ICD-10 codes beginning with October 1, 2014, dates of service. Claims without ICD-10diagnosis and inpatient procedure codes as of that date cannot be processed and will not be accepted.The current timely-filing process will continue to apply for claims submitted to Medica.

See more ICD-10 details at medica.com.Questions? Send an e-mail to ICD10Questions@medica.com.

Effective October 13, 2013:

Medica revises reimbursement policy

Medica has updated the reimbursement policy indicated below, effective with October 13, 2013, datesof processing. Such policies define when specific services are reimbursable based on the reportedcodes.

Reimbursement policies __ RevisedThese versions replace all previous versions.

Name

Medica Connections - December 2013

Time Span Codes (updated code list)

This revised policy is online or on hard copy:View reimbursement policies at medica.com; orCall the Medica Provider Literature Request Line for printed copies of documents.

Effective December 1, 2013:

Medica to revise reimbursement policy

Medica will soon update the reimbursement policy indicated below, to be effective with December 1,2013, dates of processing. Such policies define when specific services are reimbursable based on thereported codes.

Reimbursement policies __ RevisedThese versions will replace all previous versions.

NameTelehealth (updated code list)

This revised policy will be available online or on hard copy:View reimbursement policies at medica.com as of December 1, 2013; orCall the Medica Provider Literature Request Line for printed copies of documents.

Effective January 1, 2014:

Medica to revise reimbursement policy

Medica will soon update the reimbursement policy indicated below, to be effective with January 1,2014, dates of processing. Such policies define when specific services are reimbursable based on thereported codes.

Reimbursement policies __ RevisedThese versions will replace all previous versions.

NameAdverse Health Care Events (update to reflect revisions to statute)

This revised policy will be available online or on hard copy:View reimbursement policies at medica.com as of January 1, 2014; orCall the Medica Provider Literature Request Line for printed copies of documents.

Medica Connections - December 2013

Effective January 1, 2014:

Medica to revise claims processing for new patient visits

Medica will soon make a claims processing change related to the reimbursement policy listed below,beginning with January 1, 2014, dates of processing. Such policies define when specific services arereimbursable based on the reported codes.

New patient visit

According to Current Procedural Terminology (CPT®), a new patient is one who has not receivedprofessional services from the physician or qualified health care professional or any other physician orqualified health care professional in the same practice in the same specialty in the previous threeyears.

Currently when a new patient evaluation and management (E/M) code is billed that does not meet thequalifications of a new patient, the code is changed to an established patient E/M code. Beginning inJanuary 2014, a change will be phased in that will result in the denial of the new patient E/M codewhen qualifications of a new patient have not been met. The appropriate established patient E/M codewill need to be resubmitted within applicable timely-filing guidelines. For a complete list of new patientE/M codes, refer to the New Patient Visit policy on medica.com.

Reimbursement policies are available online or on hard copy:View reimbursement policies at medica.com.Call the Medica Provider Literature Request Line for printed copies of documents.

Updates to Medica Provider Administrative Manual

To ensure that providers receive information in a timely manner, changes are often announced inMedica Connections that are not yet reflected in the Medica Provider Administrative Manual. Everyeffort is made to keep the manual as current as possible. The table below highlights updatedinformation and when the updates were (or will be) posted online in the Medica Provider AdministrativeManual.

Location in manual Information updated When posted online inmanual

"Network Operation and SupportServices" section, in"Demographic Change"subsection

Added language describingprocess change for issuingdemographic-related amendmentsto provider contracts

November 2013

Medica Connections - December 2013

"Special ContractingRequirements" section

Added Qualified Health Plan(QHP) regulatory requirements forall providers providing healthservices to members enrolled in aQHP

November 2013

"Administrative Policies andProcedures" section, in "PriorAuthorization" subsection

Added details regarding providerliability and appeals related toprior authorization

November 2013

"Health Management and QualityImprovement" section, in "CareManagement" subsection (under"Benefit Appeals")

Added details regarding providerliability and appeals related toprior authorization

November 2013

For the current version, providers may view the Medica Provider Administrative Manual online.

PPO INFORMATION

Aetna changes its claim-escalation process

Aetna has made a recent change to the process that providers should pursue for claim-issueescalation. All claim issues should be initiated now through either the Aetna Provider Call Center or theAetna online resource navinet.com. The Aetna Provider Call Center has a supervisor escalationprocess to handle escalated issues. Providers who are unable to get an issue resolved should ask foran Aetna supervisor to have it escalated. Providers who do not get their issue resolved through theAetna escalation process may also contact their Medica provider analyst with the claim details.

The Aetna Provider Service Center is available at 1-888-632-3862.Providers can check the status of claims by using the secure Aetna provider website,navinet.com. It provides self-serve functionality, with reports of open and recently closed issuesas well as reprocessing status updates. For more, refer to navinet.com.

Aetna offers free monthly webinars to learn how to use its website. Providers can take trainings whenit's convenient, right from a personal computer or desktop. See more about Navinet trainings.

Latest Aetna provider bulletin available online

Medica Connections - December 2013

Aetna has published its latest edition of Aetna OfficeLink UpdatesTM (September 2013). Highlights that

may be of interest for Medica SelectCareSM and Patient Choice Insights network providers include:

Policy revision for facility special charges and incremental nursing charges __ implemented inSeptember 2013

Policy change for multiple surgical reductions to apply to mid-level practitioner claims __

scheduled for December 2013

Policy revision for therapy evaluations and re-evaluations __ scheduled for December 2013

Precertification for elective cervical and lumbar spinal fusion to be required __ scheduled forJanuary 2014

View the September 2013 Aetna provider newsletter.

Know of colleagues who should get this regularly? Have them sign up.

Medica Connections is published monthly by Medica and can be accessed online.View the Medica Connections archive.

Physician leadership at Medica:Mark Werner, MD, Senior Vice President and Chief Clinical and Innovation OfficerJim Guyn, MD, Vice President and Senior Medical OfficerTed Loftness, MD, Vice President and Medical DirectorThomas Becker, MD, Medical Director for Care Management and Reimbursement

Medica Connections editor:Hugh Curtler IIIMedica, Marketing & CommunicationsPhone: 952-992-3354Fax: 952-992-3377E-mail: hugh.curtler@medica.com

For Medica contact and reference information, see Medica points of contact for providers.

Medica Connections - December 2013

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© 2013 Medica. Medica® is a registered service mark of Medica Health Plans. "Medica" refers to the family ofhealth plan businesses that includes Medica Health Plans, Medica Health Plans of Wisonsin, Medica InsuranceCompany, Medica Self-Insured and Medica Health Management, LLC.

Medica Connections® is a registered trademark of Medica Health Plans. Medica Focus®, Medica Choice®,Medica Prime Solution®, Medica Clear Solution®, Medica AccessAbility Solution® and Medica DUAL Solution®

are registered service marks of Medica Health Plans. Patient Choice InsightsSM by Medica, Medica ChoiceCareSM and Medica SelectCareSM are service marks of Medica Health Plans. MCG Care Guidelines® is aregistered trademark of MCG Health, LLC.

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