CommercialAdministrativeHigh impact
Medica Provider News: December 2025
Medica·Rheumatology, Dermatology, Gastroenterology·Provider News
Effective date
Jan 1, 2026
We identified it
Dec 1, 2025
Summary
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.
Action Required
IMMEDIATE ACTIONS REQUIRED: (1) By December 15, 2025: Billing team must update all systems to recognize payer ID 71890 for SSM Health Employee Health Plan, Medica Employee Health Plan, Medica with SSM Health, and Medica with Mercy. Verify new group/policy numbers and member ID numbers are loaded into billing software. (2) By December 20, 2025: Verify provider credentials with Medica and respond to any recredentialing notifications received via email or U.S. mail. Contact DHSCCredentialing@medica.com if recredentialing notification is missing. Failure to respond will result in administrative termination of network participation. (3) By December 31, 2025: For IFB/Marketplace members: Configure billing system to route behavioral health claims to payer ID 87726 and chiropractic claims to payer ID 41161 (Optum Physical Health network). Update all payer lookup tables and eligibility verification tools. (4) By December 31, 2025: Front desk and billing staff must update patient communication materials and encounter forms to reflect 'Medica with SSM Health' for IFB product (name change from WellFirst Health by Medica). (5) For Nov 1, 2025 adalimumab change: Billing team must monitor for coverage transitions through January 31, 2026. Flag any adalimumab claims for Simlandi or Hadlima and work with providers to transition members to covered biosimilar alternatives or submit Exception to Coverage forms to Navitus (PBM). Ensure prior authorizations are transferred for existing therapy and obtained for new therapy. (6) By January 1, 2026: Confirm ACH/Vcard enrollment with Optum/VPay (support@vpayusa.com or 855-893-3029) for self-funded plans under payer ID 71890 to ensure payment receipt. (7) Update all Availity transactions to use correct payer IDs from drop-down menu (71890 for Medica Health Plan Solutions, 41822 for existing plans, 75261 for Dean Health Plan). Consequences: Claims will be denied, providers may be terminated from network for non-compliance with recredentialing, and payments may not be received if vendor enrollment is not completed.