Medica Provider News: August 2025

REQUIREMENTS: 1. By August 14 or August 19, 2025 (training dates): Billing and clinical staff should register for and attend Availity MCG Integration for Authorizations training to learn the new prior authorization submission workflow with integrated clinical criteria questions. 2. Immediately: Update all bookmarks and system links from mrxgateway.com to gatewaypa.com for Prime Therapeutics medical benefit drug UM policies. The old URL no longer redirects and will generate error messages. 3. By October 1, 2025: Cease referencing the Medical Injectables List (MIL) for prior authorization determinations. Transition to accessing medical benefit drug UM policies via the Prime Therapeutics gatewaypa.com website or Medica's Medical management webpage under "Medical drug PA policies." 4. Immediately: Train billing staff to recognize CARC code OA 257 and RARC code N617 on Provider Remittance Advice (PRA) and Explanation of Payment (EOP) statements. These codes indicate IFB members in premium grace period months 2-3 with claims on hold. Do NOT bill members or providers for these denials—neither has liability. Only pursue payment if "PR" (patient responsibility) code appears. 5. Immediately: Update prior authorization submission routing: - Medical drug prior authorization: Fax to 1 (608) 252-0814 (NOT Availity Essentials) - Prescription drug prior authorization: Submit via Navitus portal (NOT Availity Essentials) - Radiology, cardiology, and musculoskeletal prior authorization: Use Carelon portal (NOT Availity Essentials) - Other services: Use updated Availity Essentials portal with clinical criteria integration 6. Ongoing: When receiving claim denials for IFB members with stated ineligibility, verify member active status via Availity Essentials eligibility transaction. If active, check for "HIX Grace Period" notation under Health Benefit Plan Coverage section before appealing or rebilling.