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Administrative Resources

Medica Administrative Manual

The administrative manual is a resource for all clinic and facility staff, including physicians and other health care providers, nurses, and all business staff. This manual ensures that you have accurate and timely information about Medica products, programs, policies and procedures.

  • Administrative Policies and Procedures: Prior authorization and notification requirements, high-tech imaging, special transportation forms and guidelines, medical records reimbursement and dispute resolution.

  • Billing and Reimbursement: Information on mailing address for claims, claim submission requirements, recovery processes, coding resources, reimbursement policies, member liability, failure to comply and electronic transactions.

  • Fraud and Abuse: Medica's position on and investigation of fraud and abuse, Medica’s Special Investigations Unit (SIU), financial and health record-keeping requirements and CMS Fraud, Waste and Abuse Compliance Training requirements.

  • Glossary of Terms: An alphabetical list of all terms within the Medica Provider Administrative Manual.

  • Health Management and Quality Improvement: Information on our case management programs, health care homes certification, clinical appeal guidelines, quality improvement programs, clinical reviews, quality reporting obligations and Centers of Excellence program, as well as termination and continuity-of-care requirements.

  • Medica Points of Contact: An overview of Medica’s information and service resources for participating providers.

  • Member Care: Resources to help you provide better care to your patients.

  • Network Operation and Support Services: Answers to questions on your existing contract or learn how to become contracted with Medica. Also find information regarding Credentialing and Demographics and our complementary network Medica Behavioral Health.

  • Pharmacy Services: Pharmacy policies and procedures, pharmacy related announcements and the drug lists.

  • Product Portfolio: Benefit information and overviews for each of our products, including ID card information and network restrictions.

  • Regulatory Reporting: Federal and state rules that impact participating providers, including HIPAA requirements.

  • Special Contracting Requirements: Requirements, including provider requirements for Medicare, Medicaid, and state government program products, liability insurance, subcontracting, special transportation driver and vehicle services, interpreter services, telemedicine and critical access and rural health.
Date: 10/24/2017 12:41:40 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB01