Medica Provider News: July 2026

IMMEDIATE (By July 1, 2026): Billing team must ensure all medical benefit drug prior authorization requests are submitted through Prime Therapeutics Gateway portal instead of direct Medica submission. Update internal workflows and provider communication to reflect this change. ONGOING: When submitting Eligibility and Benefit Inquiry transactions, billing team must include patient first name, last name, subscriber ID, and date of birth on every request to maximize success rates and reduce 'member not found' errors. For Claim Status Inquiry transactions in Availity Essentials portal, always use the billing provider's NPI (not rendering provider's NPI) to avoid 'claim not found' errors. BEFORE October 1, 2026: Update billing system reimbursement rules to reflect that claims billed with modifier 78 (return to operating room) will be reimbursed at the intraoperative percentage per CMS National Physician Fee Schedule (currently 84% but subject to CMS updates), effective Oct. 1, 2026, for processing dates. This applies to commercial and Individual and Family Business (IFB) plans. FOR DOCUMENTATION: Providers must ensure depression screening follow-up is documented within 30 days of positive screens using structured documentation (flowsheets, SmartForms, coded data); ensure documentation appears in primary care record and includes specific follow-up actions. ADMINISTRATIVE: Review and update provider demographic information in Medica systems and NPPES regularly; notify Provider Network Relationship Specialist of any changes to practice details, locations, or terminations with advance notice.