Moda Medical Office Update

New Partnership announcement for Infusion and Enteral Therapies

We are excited to announce a new partnership between Emerging Health and Moda Health!

Emerging Health is a new, locally owned, and operated home infusion and ambulatory infusion center located in Southwest Portland.

Emerging Health offers the following services and therapies:

Home Infusion: Patients can receive treatment in the comfort of their homes. Personalized care options give patients freedom that fits their lifestyle.

Ambulatory Infusion Center (AIC): The ambulatory facility in Southwest Portland provides a safe and supportive setting for patients and caregivers. Patients receive care in a private infusion suite. They also have a suite designed just for children.

Enteral Therapy: Local 1:1 education, monitoring, and assessments from board-certified nutrition support clinicians for tube-fed patients.

The Emerging Health Difference

Emerging Health strives to exceed expectations and ensure patients and their caregivers have positive and thoughtfully coordinated experiences. They view their service as an extension of the care you and your staff provide.

Emerging Health ensures safety, comfort, and convenience by offering treatment in one of their private infusion suites or in the patient’s home

Their local, experienced pharmacy team prepares and packs all medication, supplies and equipment

Patients receive personalized care plans that incorporate all aspects of their lives

Their team uses advanced technologies and medical innovations to improve the experience and outcomes of their patients

You get live, local support to coordinate intake, authorization and billing for Moda Health plan members

To learn more, place a referral or arrange for a tour of our facility, please call 877-290-2040.

COVID Vaccines

As the global COVID-19 pandemic progresses, the vaccine landscape continues to be studied and recommendations evolve. The CDC recommends preventing the COVID-19 virus and variants by one of three available vaccines: the Pfizer-BioNTech vaccine, COMIRNATY® (granted full FDA approval), Moderna (authorized by the FDA) and Janssen (authorized by the FDA¹).

The recommendations are summarized below:

1. Pfizer-BioNTech COVID-19 Vaccine (COMIRNATY®)^2,3

- FDA grants full approval to COMIRNATY as a two-dose series in persons 16 years of age and older effective Sept. 23, 2021

- The Emergency Use Authorization (EUA) remains in place for the following populations:

Two dose series in persons 12 to 15 years of age
Third dose administered at least 28 days following the second dose for persons 12 years of age and older with a solid organ transplant or who are diagnosed with other conditions with an equivalent level of immunocompromise

2. Moderna COVID-19 Vaccine⁴

Available under EUA authorization for the following indications:

Two-dose series in persons 18 years of age and older
Third dose administered at least 28 days following the second dose for persons 18 years of age and older with solid organ transplant or who are diagnosed with other conditions with an equivalent level of immunocompromise

3. Janssen (J&J) COVID-19 Vaccine⁵

Available under EUA authorization for the following indications:

Single-dose series in persons 18 years of age and older

When a third dose is indicated for those who are moderately to severely immunocompromised, the mRNA vaccine given should match the vaccine used in the initial two-dose series. If you cannot get the product, you can use the vaccine from the other manufacturer.

At the time of writing, an FDA advisory panel recommends a booster dose of the Pfizer-BioNTech COVID-19 vaccine for people 65 years and older, those at high risk for severe COVID infection, and for healthcare professionals or others at high risk for occupational exposure. Adoption of this recommendation by the FDA is expected soon.⁶ Additionally, Pfizer stated their intention to submit data to the FDA by the end of September showing vaccine efficacy in children age 5 to 11 years.⁷ It should be noted that regardless of booster doses, data shows that the original vaccine series remains highly effective against the spread of virus and prevention of serious illness, hospitalization and/or death from COVID-19.

As flu season approaches, vaccination with both the COVID-19 and flu vaccines should be pursued. These vaccines can be administered at the same time.

References

Centers for Disease Control and Prevention. COVID-19 ACIP Vaccine Recommendations. last updated 30^th August 2021. Accessed from: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html
U.S. Food and Drug Administration. Pfizer-BionTech COVID-19 Vaccine EUA Letter of Authorization. 23 August 2021. Accessed from: https://www.fda.gov/media/150386/download
U.S. Food and Drug Administration. COMIRNATY Approval Letter. 23 August 2021. Accessed from: https://www.fda.gov/media/151710/download.
U.S. Food and Drug Administration. Moderna COVID-19 Vaccine EUA Letter of Authorization. 12 August 2021. Accessed from: https://www.fda.gov/media/144636/download
U.S. Food and Drug Administration. Janssen COVID-19 Vaccine EUA Letter of Authorization. 10 June 2021. Accessed from: https://www.fda.gov/media/146303/download
AMCP Daily Dose. FDA Panel Voted To Recommend Coronavirus Boosters for Older Adults And Individuals At Risk Of Serious Illness. 17 September 2021. Accessed from: https://amcp.bulletinhealthcare.com/?tokenid=d9838216n7465iq72255172272465iq7225kj941&dt=20210921&d=2021-09-20&a=S1
Lovelace B. Pfizer CEO says Covid vaccine datea for kids under age 5 may come in late October. 14 September 2021. Accessed from: https://www.cnbc.com/2021/09/14/pfizers-covid-vaccine-data-for-kids-under-age-5-may-come-in-late-october-ceo-says-.html

Compassionate kidney care

Moda Health has partnered with Strive Health to provide members with chronic kidney disease stages 3, 4 and 5, and end-stage renal disease will receive kidney disease care coordination services. The Strive Health proven care model intervenes early to help slow kidney disease progression, reduce dialysis crashes, increase home dialysis adoption and reduce hospitalizations.

Our partnership with Strive Health offers members:

24-hour-a-day access to a kind and knowledgeable team of Kidney Heroes™
Convenient scheduling options, including telehealth and home visits
Access to experts in kidney care who want you to have a great experience
Care coordination with the member’s healthcare providers
Coaching for diet, exercise and stress management

If interested in learning more about Strive Health, please contact [email protected].

Transitions of Care (TRC) medical record review project

We’ve partnered with KDJ Consultants to assist with off-season chart retrievals for the Transitions of Care measure. We encourage you to allow remote access to minimize Covid-19 exposure and reduce administrative burden.

To establish, please contact [email protected] or call 503-412-4001. We greatly appreciate your assistance with this project.

Reimbursement Policy Updates

Policy

Reason for review

Summary of update

Reviewed in August, 2021

RPM013, “Modifiers 80, 81, 82 and AS - Assistant At Surgery”

Annual review

Removed references to EOCCO, as we now have more than one Medicaid plan
Scope section: Added Summit Health plan
Converted to outline format
Section D, updated Medicare Advantage and Medicaid rates
Acronym table: Added 15 listings
Important statement section wording updated
Minor grammar and format updates

RPM022, “Modifier 51 - Multiple Procedure Fee Reductions”

Annual review

Removed references to EOCCO, as we now have more than one Medicaid plan
Scope section: Added Summit Health plan
Added section A.3.
Section B.3, C and D wording simplified to “Effective July 1, 2018…”
Section C.4 and D.4 added to provide instructions for questions about guidelines prior to July 1, 2018
Section C and D updated to reflect that CMS, ASC and OPPS multiple procedure indicators are applied
Background section moved to follow References and Resources section
Important statement section wording updated

RPM056, “Medically Unlikely Edits (MUEs)”

Annual review

Removed references to EOCCO, as we now have more than one Medicaid plan
Scope section: Added Summit Health plan
Section A.1.a and c: Added clarification that ASC claims on CMS1500 claims are subject to Professional MUEs, but hospital-based ASC claims on UB/CMS1450 claims are subject to OPPS MUEs
Acronym table added multiple listings
Important statement section wording updated
Minor format updates

RPM058, “Behavioral Health Case Management and Care Coordination”

Annual review

Sections B.1.d and B.2.d: Added H0040 as eligible for licensed behavioral health professionals (B.1.d.) and Qualified Mental Health Professionals (B.2.d.)
Section D: H0040 reason column updated with date information
Minor format updates

Note: There are no policies that have been reviewed during September for this newsletter. Review is in progress on a number of policies, but no updates have been completed, approved, and posted.

Medical criteria changes July/Aug 2021

Medical criteria

July medical criteria summary

Pharmacy/medical

Panniculectomy

(abdominal skin/fat surgery)

Introduction: This is annual review.

Criteria changes: Title updated to “Panniculectomy (abdominal skin/fat surgery) to align with policy indications

Medical

Endoscopic procedure for

treatment of GERD

Introduction: This is annual review.

Criteria changes: No content changes

Medical

Genetic testing

Introduction: This is an annual review.

Criteria changes: Expanded the indications for breast cancer index coverage. Added coverage requirements for risk stratification for uveal melanoma.

Medical

Mobile outpatient cardiac telemetry

Introduction: This is an annual review.

Criteria changes: No content changes

Medical

Negative pressure wound therapy (vacuum-assisted wound closure)

Introduction: This is an annual review:

Criteria changes: No content changes

Medical

Serum antibodies for diagnosis of inflammatory bowel disease

Introduction: This is an annual review:

Criteria changes: No content changes

Medical

Air ambulance transport

Introduction: This is an annual review.

Criteria changes: Language update, ”scheduled” non-emergent air transport

Medical

Medical nutrition

therapy/nutritional counseling

Introduction: This is an annual review/update.

Criteria changes: Nutritional therapy criteria for eating disorders folded into this criteria set. Changed criteria for eating disorders so that the diagnosis alone is sufficient to satisfy criteria. Retire separate policy BHC 0013.

Medical

Medical criteria

August medical criteria summary

Pharmacy/medical

AFO-KAFO_HKAFO

Introduction: This is annual review.

Criteria changes: No changes

Medical

Cranial orthotics

Introduction: This is annual review.

Criteria changes: No changes

Medical

Factor V Leiden Thrombophilia-F5 Gene

Introduction: This is annual review.

Criteria changes: No changes

Medical

Knee cartilage transplants

Introduction: This is annual review.

Criteria changes: No changes

Medical

Obstructive sleep apnea (OSA) non-surgical treatment

Introduction: This is annual review.

Criteria changes: No changes

Medical

Push-rim activated power assist device

Introduction: This is annual review.

Criteria changes: No changes

Medical

Therapeutic drug monitoring (TDM)

Introduction: This is annual review.

Criteria changes: No changes

Medical

Upper extremity orthoses

Introduction: This is annual review.

Criteria changes: No changes

Medical

Moda Medical Customer Service

For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email [email protected].

Moda Provider Relations

For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests please email [email protected]

Provider Updates

For provider demographic and address updates, please email [email protected].

Credentialing Department

For credentialing questions and requests, please email [email protected].

503-228-6554 | [email protected] | modahealth.com