What types of policy changes does Medica issue?

Medica regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does Medica update its policies?

Medica typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many Medica policy changes are tracked here?

This page currently tracks 14 documented Medica policy changes. New items are added as they are identified.

What should I do when Medica changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

Medica Policy Changes & Prior Auth Updates

We track 14 documented policy changes from Medica across IL, MO, WI. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Medica notice. Use the related links below to narrow results by specialty or state, or sign up for a free daily alert to receive new Medica updates automatically.

Medium impact
Medica Provider News: August 2026
Medica·Effective Sep 1, 2026
Medica is decommissioning its provider portal effective September 1, 2026. After July 1, 2026, all claim appeals for payer ID 39113 must be submitted via fax or mail using the Claim Adjustment or Appeal Request Form instead of the portal. Starting September 1, providers must contact the Provider Service Center (1-800-458-5512) for claims status and appeal status inquiries. Additionally, providers must sign up for newsletters and Provider Alerts using a new centralized e-communications form on Medica.com, as portal-based management will no longer be available.
High impact
Medica Provider News: May 2026
Medica·Effective Aug 1, 2026
Effective August 1, 2026, Medica will require prior authorization for preferred biosimilar IV infliximab (Avsola, Renflexis) and IV ustekinumab (Steqeyma, Yesintek) products. Additionally, starting July 1, 2026, Prime Therapeutics will assume management of specialty drug prior authorization requests, replacing the current fax-based process with an online portal system. These changes affect Commercial, IFB, ASO, and Medicare Advantage members.
High impact
Medica Provider News: July 2026
Medica·Effective Jul 1, 2026
Medica has implemented multiple policy changes effective July 1, 2026, including transfer of medical benefit drug prior authorization to Prime Therapeutics (requiring submission via Prime Gateway portal), launch of new EDI best practices guidance to improve claim and eligibility submission success rates, and upcoming Global Days reimbursement policy changes effective October 1, 2026. Additionally, the policy reinforces documentation requirements for depression screening follow-up and reminds providers to maintain current demographic information.
High impact
Medica Provider News: June 2026
Medica·Effective Jul 1, 2026
Medica is implementing multiple administrative changes effective June-September 2026: (1) Prime Therapeutics will manage all medical benefit drug prior authorizations starting July 1, 2026, requiring submission through Prime's portal instead of fax; (2) the secure provider portal will shut down September 1, 2026, with migration to Availity Essentials; (3) a new Provider Service Center telephony system launches in late June 2026; and (4) commercial drug formulary changes effective July 1, 2026. Billing teams must transition prior authorization workflows and update portal access procedures before these dates.
High impact
Medica Provider News: April 2026
Medica·Effective Jul 1, 2026
Effective July 1, 2026, Medica is transferring management of all medical benefit drug authorizations to Prime Therapeutics for specialty professionally administered drugs. Prior authorization requests must be submitted through Prime's Gateway portal instead of by fax to Medica. Additionally, CPT code 29826 (arthroscopic subacromial decompression) no longer requires prior authorization effective February 1, 2026.
High impact
Medica Provider News: February 2026
Medica·Effective Jan 1, 2026
Medica has updated prior authorization routing requirements and eliminated admission notification requirements for labor and delivery services effective January 1, 2026. Billing teams must route prior authorization requests through different portals based on service type (Availity Essentials for general medical, Carelon for radiology/cardiology/musculoskeletal, Navitus/Evernorth for pharmacy, Prime Therapeutics for medical drugs) and stop submitting labor and delivery admission notifications.
High impact
Medica Provider News: January 2026
Medica·Effective Jan 1, 2026
Medica is implementing multiple operational changes effective January 1, 2026, including: (1) migration of all electronic transactions to Availity Essentials portal for most plans, (2) new payment vendor (Optum VPay) for self-funded plans under payer ID 71890, (3) network changes for Medica with SSM Health members affecting behavioral health and chiropractic services, and (4) initiation of ACA chart review audits for 2025 dates of service with completion deadline of March 2026. Billing teams must update portal access, payment processing workflows, and prepare for medical record retrieval requests.
High impact
Medica Provider News: December 2025
Medica·Effective Jan 1, 2026
Medica is implementing multiple operational changes effective January 1, 2026, including payer ID transitions for four commercial products (moving to payer ID 71890), payment vendor changes to Optum/VPay for self-funded plans, network changes for IFB/Marketplace members (new behavioral health and chiropractic networks with different payer IDs), and a biosimilar coverage change for adalimumab products effective November 1, 2025. Additionally, administrative terminations will occur for providers who do not respond to recredentialing requests within 36 months.
High impact
Medica Provider News: September 2025
Medica·Effective Dec 1, 2025
Medica is implementing three significant reimbursement policy changes effective December 1, 2025: (1) Multiple Procedure Payment Reduction (MPPR) for diagnostic imaging will now apply to certain ultrasound CPT codes without MPI indicator 4 on commercial and IFB plans; (2) a new Replacement Codes policy requiring use of CMS-designated replacement codes with assigned RVUs for status code 'I' codes on commercial and IFB plans; and (3) a new Device, Implant, and Skin Substitute policy requiring devices/implants to be submitted on the same day and claim as the procedure, or the procedure will be denied on commercial, Medicare, and IFB plans. Additionally, the policy clarifies that discarded drugs/biologicals must use modifier JW for the unused portion (not eligible for payment) across all plan types.
High impact
Medica Provider News: August 2025
Medica·Effective Oct 1, 2025
Medica has updated its prior authorization submission process through Availity Essentials portal with integrated clinical criteria questions to streamline approvals. Additionally, the Medical Injectables List (MIL) will be retired effective October 1, 2025, with medical benefit drug UM policies now accessible through the Prime Therapeutics gatewaypa.com website. IFB members in premium grace periods (months 2-3) will have claims held with specific CARC/RARC codes (OA 257 and N617) indicating no provider or member liability until premiums are paid.
High impact
Medica Provider News: July 2025
Medica·Effective Oct 1, 2025
Medica is implementing multiple policy changes effective October 1, 2025: retiring the Medical Injectables List (providers must use Prime Therapeutics website instead), and revising IONM reimbursement requirements to mandate Study Code and Place of Service codes 19/21/22/24 with prohibition on billing by surgeons/anesthesiologists. Additionally, credentialing procedures are being enhanced effective immediately with new locum tenens requirements, health equity language mandates, monthly license expiration reviews, and changes to recredentialing notification letters starting October 1.
Medium impact
Medica Provider News: March 2026
Medica·Effective May 1, 2026
Effective May 1, 2026, Medica will remove medical benefit coverage for subcutaneous ustekinumab products. Coverage will shift to the pharmacy benefit for commercial, IFB, and integrated pharmacy/medical plans. Billing teams must identify affected claims, verify pharmacy benefit coverage with members' PBMs, and route claims to pharmacy instead of medical for SC ustekinumab on or after the effective date to prevent denials.
Medium impact
Medica Provider News: November 2025
Medica·Identified Nov 1, 2025
Failed to analyze policy change
Medium impact
Medica Provider News: October 2025
Medica·Identified Oct 1, 2025
Failed to analyze policy change

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Medica Policy Changes 2026 | Prior Auth & Coverage Updates | PolicyChanges.app

Medica Provider News: August 2026

Medica Provider News: May 2026

Medica Provider News: July 2026

Medica Provider News: June 2026

Medica Provider News: April 2026

Medica Provider News: February 2026

Medica Provider News: January 2026

Medica Provider News: December 2025

Medica Provider News: September 2025

Medica Provider News: August 2025

Medica Provider News: July 2025

Medica Provider News: March 2026

Medica Provider News: November 2025

Medica Provider News: October 2025