New COVID-19 Therapeutics Locator

The U.S. Department of Health and Human Services (HHS) has released a new and improved COVID-19 Therapeutics Locator website. The new site uses public HHS data on shipments of U.S. Government-procured COVID-19 therapeutics under U.S. Food and Drug Administration Emergency Use Authorization (EUA) authority.
 
Therapeutics currently available under EUA include products intended for COVID-19 prevention and monoclonal antibody treatments, including:

Prevention
  • Evusheld (AstraZeneca)

Monoclonal antibody treatments
  • Bebtelovimab (Lilly)
  • Sotrovimab (GSK)

Oral antiviral therapies
  • Paxlovid (Pfizer)
  • Molnupiravir (Merck)
 
The website displays the number of courses available for each therapeutic, alongside an interactive map. Users can:
  • Zoom-in on the area of interest to see data on available therapeutics by location as reported within the last seven days
  • Search by location (state, territory or jurisdiction)
  • Filter by therapeutic
 
Search results include location name, address, therapeutic name and NDC, and number of courses available.
Retacrit supply disruption

Pfizer announced it expects a supply disruption for its short-acting erythropoiesis-stimulating agent (ESA), Retacrit (epoetin alfa-ebpx). The forecasted disruption is expected to start May 2022 and last through Q4 2022. In anticipation of the market shortage, Moda Health will temporarily modify our process to minimize the disruption to your patients and practice.
 
How will this impact you and your patients?
For patients currently receiving Retacrit, you can seamlessly switch to another epoetin alfa agent (Epogen/Procrit), and Moda will cover the drug at the same level as Retacrit.
 
For patients initiating treatment with an ESA during the shortage, the requirement to use Retacrit before Epogen/Procrit will be waived. Access to Epogen/Procrit will be approved when prior authorization criteria are met during the active shortage period.
 
Once supply returns, Moda will go back to our pre-shortage policy and process. Providers currently prescribing ESAs will be receiving more information in the mail. You can monitor FDA drug shortages here.
Medicare Part B step therapy updates

On Jan. 1, 2021, Moda Health implemented step therapy requirements for Medicare outpatient (Part B) medications. Step therapy is required for certain medications, but only if the following are met for the requested drug:

  • Meets the definition of a Medicare Part B medication
  • New for the patient, as defined by no use in the last 365 days
  • Proposed use of the requested and alternative drug has been determined to be a medically accepted indication under Medicare rules
  • Dose, frequency and duration of use may not exceed the safety and efficacy data supporting the medically accepted indication 
 
Outlined below are the changes to the preferred products starting July 1, 2022.
Preferred medication(s) [HCPCS]
Non-preferred medication(s) [HCPCS]
Benlysta [J0490]
Saphnelo [J3590]
Repatha [J9999] OR Praluent [J9999]
Leqvio [J3490]
Avastin - Ophthalmic 
Vabysmo [J3590], Susvimo [J3590]
To see the full list of Medicare Part B Step Therapy medications, please visit our
Medicare Advantage and Summit Health valued-based contract

At Moda Health and Summit Health, we offer providers to opt-in to the Medicare Advantage Primary Care Incentive Program (MAPCIP). They are eligible to earn a per member per month (PMPM) Care Gap Incentive Payment (CGIP). This rewards performance for meeting set thresholds for quality measure gap closures, as well as an additional PMPM Access to Care Incentive Payment (ACIP) for certain annual physical or wellness visit thresholds.
 
Your office should have received the 2022 MAPCIP contract. Please complete and return it to contractrenewal@modahealth.com to confirm your participation for this year. You’ll also be rewarded for the services you are already providing to your patients.
 
Questions?
For any questions, please email contractrenewal@modahealth.com.
Behavioral health resources for older adults
and people with disabilities

To better meet the needs of older adults and people with disabilities, we’re here to improve timely access to care from qualified providers who work together to provide coordinated, quality and culturally responsive behavioral health and wellness solutions.
 
The Behavioral Health Initiative for Older Adult and People with Physical Disabilities, funded by the Oregon Health Authority, offers resources for both providers and patients. The website includes training modules for providers, a listing of upcoming events, and other resources to help you support your patients.
 
Please reference their Expanding Behavioral Health Services through Medicare Factsheet to see how behavioral health services can be delivered under Medicare. This includes billing codes for Health and Behavioral Assessment and Intervention (HBAI) and Behavioral Health Integration (BHI).
Reimbursement Policy Updates

The following tables include RPM policy updates for December 2021
and January 2022.
Policy
Summary of update
Reviewed in February 2022
RPM005, “Records Fees,
Copying Fees”
  • Scope – Added Summit Health
  • Information added for Texas
  • Acronym table – Added
  • Coding Guidelines & Sources – Added
  • References & Resources – Added seven listings
  • Converted to outline format. Other minor rewording; no content changes.
RPM020, “Maternity Care”
  • Sections J.1., O.1., O.1.b.i. – Reworded for Texas
  • Section O.1.b.ii. – Added for Texas
  • References & Resources – Added # 24 & 25
RPM024, “Modifier SL - State Supplied Vaccine”
  • Scope – Added Summit Health
  • Acronym table – Added
  • Coding Guidelines – Added Texas information
  • References & Resources – Added # 7
  • Minor formatting adjustments
RPM052, “Telehealth and Telemedicine Services”
  • Modifier 93 (new for 2022) information added
  • Section B & Definition of Terms – Telemedicine Note 1 – Updated for HB 2508 updates to ORS 743A.058
  • Section B.10.a. – Additional wording & examples added
  • Section D – Added for Texas
  • Section E.2.a.ii., E.2.e., – Added from transmittal R11219BP
  • Acronym Table – Added 2 entries
  • References & Resources – Added # 33 - 37. Updated # 20
  • Other minor rewording; no content changes
Clarification, no policy changes:
RPM053, “Diagnosis Code Requirements – Level of Detail, Number of Characters, and Laterality”
  • Sections B.4 & B.5 - Clarification per provider inquiry received
Annual review:
RPM015, “Drugs and Biologicals, Wastage and/or Discarded Amounts (Modifier JW)”
  • Scope – Added Summit Health plan
  • Acronym table – Added
  • Minor formatting adjustments & minor rewording
RPM016, “Clinical Drug Screening and/or Drug Testing”
  • Scope – Added Summit Health plan
  • Acronym table – Added
  • Archived 2016 information
  • Formatting improvements, minor rewording without content changes
RPM019, “Valid Modifier to Procedure Code Combinations”
  • Scope – Added Summit Health plan
  • Acronym table – Added
  • Archived 2016 information
  • Formatting improvements, minor rewording without content changes
RPM045, “Reference (Outside) Laboratory – Modifier 90”
  • Scope – Added Summit Health. Removed EOCCO
  • Acronym table – Added
  • Other minor rewording; no content changes
RPM057, “Modifier 50 – Bilateral Procedure”
  • Scope – Added Summit Health. Removed EOCCO
  • Acronym table – Added 6 listings. EOCCO removed
  • Formatting improvements, rewording without content changes
Policy
Summary of update
RPM063, “340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB)”
  • Scope – Added Summit Health
  • Acronym table – Added 8 listings. EOCCO removed.
  • Formatting improvements, rewording without content changes
Reviewed in March 2022
Revision/update:
RPM073, “Telehealth and Telemedicine Expanded Services for COVID-19”
  • Section B.2. – added to address modifier 93
  • Changed Header listing of "Section" from "Medicine" to "Administrative" to match RPM052
  • Section B.6: added 3 footnotes
  • References & Resources: Updated # 21. Added # 27 - 29.
Annual review:
RPM021, “Medical, Surgical, and Routine Supplies (including but not limited to 99070)”
  • Scope - Added Summit Health
  • Formatting improvements, no content changes
RPM022, “Modifier 51 - Multiple Procedure Fee Reductions”
  • Scope – Updated listing for Summit Health
  • Formatting improvements, rewording without content changes
RPM025, “Add-on Codes”
  • Scope – Added Summit Health
RPM026, “Operating Microscope (CPT Code 69990)”
  • Scope – Added Summit Health
  • Formatting improvements, rewording without content changes
RPM048, “Moderate (Conscious) Sedation”
  • Scope – Added Summit Health
  • Acronym Table: Added 9 entries
Medical Necessity Criteria updates

The following table includes medical criteria updates for
February 2022.
Criteria
February
Medical Criteria Summary
Pharmacy/medical
Allergy testing – Blood
Introduction: This is an annual review.
 
Criteria changes:
  • Listed ICD 10 codes that may not be covered with requests for ALCAT using CPT code 83516
  • Removed ALCAT testing Investigational indication, retains noncovered indication with listed Dx codes
Medical
Cardiac disease screening – Lipid profile
Introduction: This is an annual review
Criteria changes: No changes

Medical
External infusion insulin pumps
Introduction: This is an annual review.
 
Criteria changes:
  • Indicated pumps and supplies are FDA approved
  • History of recurring hypoglycemia changed to less than 70 mg/dl
Medical
Extracorporeal shock wave treatment
Introduction: This is an annual review
Criteria changes: No changes
Medical
Kyphoplasty/ Vertebroplasty
Introduction: This is an annual review
Criteria changes: No changes
Medical
Obstructive sleep apnea – Surgical treatment
Introduction: This is an annual review
Criteria changes: No changes
Medical
Prophylactic mastectomy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Skin & tissue substitutes – Engineered
Introduction: This is an annual review.
 
Criteria changes: New 2022 codes added, updated renamed skin substitute-Kerecesis omega 3 wound, added EpiCord to the guidelines section
Medical
Virtual colonoscopy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Contact us
Moda Health Medical Customer Service
For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email medical@modahealth.com.
 
Moda Provider Relations
For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests please email providerrelations@modahealth.com
Provider Updates
For provider demographic and address updates, please email providerupdates@modahealth.com.


Credentialing Department
For credentialing questions and requests, please email credentialing@modahealth.com.

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