In this issue Emerging Health COVID-19 Therapeutics Locator Retacrit supply disruption Medicare Part B Step Therapy update 2022 Moda Health Medicare Advantage and Summit Health Value-Based Contract OHA Behavioral Health Initiative Factsheet Reimbursement Policy updates  Medical Necessity updates Join our email list Join our email list in order to begin receiving bi-monthly newsletters, as well as occasional electronic communications.

Changes to Moda Health’s Enteral Therapy Network  Starting March 15, 2022, Option 1 Northwest Enteral LLC is no longer an in-network provider with Moda Health. To continue providing statewide enteral services to our Oregon members, we are excited to announce a new partnership with Emerging Health.   Emerging Health is a new, locally owned and operated home infusion and statewide enteral therapy provider in Southwest Portland. Emerging Health offers the following services and therapies: Enteral therapy: Local 1:1 education, monitoring and assessments from board-certified nutrition support clinicians for tube-fed patients. 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 located 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.   An extension of care Emerging Health strives to exceed expectations and ensure patients and their caregivers have positive and thoughtfully coordinated experiences. They see their service as an extension of the great care you and your staff provide, including:  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 change your patient’s prescription to Emerging Health or another in-network enteral provider, just contact one of the resources, below: Emerging Health Phone: 877-290-2040 Email: [email protected]   Moda Health Customer Service Phone: 888-217-2363 Email: [email protected]

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 step therapy requirements and referral and prior authorization guidelines web pages.

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 [email protected] 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 [email protected].

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 [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].

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