In this issue CPC+ replacement Provider Diversity Medicare care guides for your patients MA Organizational Determination Naloxone Medication Use Evaluation (MUE) Reimbursement Policy updates Medical Necessity Criteria updates Join our email list Join our email list in order to begin receiving bi-monthly newsletters, as well as occasional electronic communications.

CPC+ replacement We would like to thank you for your partnership and engagement in the CPC+ program for the last five years. Our shared dedication to strengthening primary care through quality improvement and adoption of new payment methodologies has helped make this program successful. As we approach the end of the program (Dec. 31, 2021), we want to let you know that we plan to continue to support primary care transformation in Oregon. We are currently designing a CPC+ replacement program that will support the expansion of value-based care incentives for Commercial and Medicare Advantage lines of business. In the coming months, we will be communicating the details of these programs and asking for your participation. Questions? We’re here to help! For more information on participating in our value-based care programs, please email [email protected]. Sincerely, Moda Health Medical Provider Relations

2021 Provider Diversity, Equity & Inclusion Survey We have been working for many years to weave the pillars of diversity, equity and inclusion (DEI) into everything we do.   Diversity: We value, respect and celebrate people of all backgrounds, identities and abilities. And, we actively seek to identify how uniqueness makes us better. Equity: We strive to understand the underlying causes of outcome disparities and actively work to increase justice and fairness in our processes, procedures and systems. We do this within our company and within our communities. Inclusion: We are committed to creating environments where every individual has an equal opportunity to belong and can be recognized for their inherent worth and dignity.   As part of our commitment to DEI, we invite you to share your demographic information with us. That way, our members can choose providers with whom they have commonalities.   In the current workforce, diversity among physicians is limited. Mounting evidence suggests when physicians and patients share the same race or ethnicity, it improves: Time spent together Medication adherence Shared decision-making Wait times for treatment Screening adherence Patient understanding of health risks Patient perceptions Treatment decisions   Would you consider sharing this information with us?   You can share your info by completing a quick, online survey available on any of the following websites:   Oregon Medical & Behavioral Health Providers: modahealth.com/medical/forms.shtml Alaska Medical & Behavioral Health Medical Providers: modahealth.com/medical/forms.shtml EOCCO Providers: eocco.com/providers/forms Thank you for partnering with us!

Personalized care guides for your patients Moda Health and Summit Health are launching a new initiative to educate and help your Medicare Advantage patients schedule their recommended preventive services. We ask that you work with your patients on their open gaps in care and complete those that are appropriate for their overall health management.   We recently mailed care guides to eligible Moda Health and Summit Health members, based on their medical and pharmacy claims information. These guides are personalized reminders for your patients about their gaps in care. They will remind your patients about services for which they may be due, including Annual Wellness Visits, cancer screenings, routine diabetes care, and more.   Many of these are directly tied to Star Measures, and others have an indirect opportunity to impact quality measures. Closing these care gaps can lead to better health outcomes.   Our staff of highly trained Health Advocates will follow up by phone in June, to a high-risk segment of the population to provide additional support and health education.   Your office may receive calls from our Health Advocates or directly from your patients to schedule their recommended preventive services. Please be sure to code services accurately, for both your own reimbursement and quality measure reporting. Learn more about Medicare Preventive Services at the Medicare Learning Network.

Pre-service organization determination for Medicare Advantage members The Centers for Medicare and Medicaid Services (CMS) prohibits the use of the Advanced Beneficiary Notice (ABN) form for Medicare Advantage enrollees.   Unlike members enrolled in the Fee-for-Service (Original) Medicare program, Medicare Advantage (MA) enrollees have the option to get a coverage decision before receiving the item or service. This coverage review is a request for a pre-service organization determination. The MA plan will review the request and issue an approval or denial based on its review if: A member is seeking services covered under Original Medicare or the MA plan. Then, a pre-service organization determination is not required (keeping in mind that this does not negate the pre-authorization requirement if a service requires it). A member is seeking services that are either statutorily noncovered services under Original Medicare or noncovered by the MA plan. Then, a pre-service organization determination is required to protect the member.    Please note that either the enrollee or the provider can request an organizational determination. However, we encourage our contracted providers to use our current structure for requesting a pre-service organization determination on the enrollee's behalf.   To request a pre-service organization determination for Moda Health MA members, please call 800-258-2037 or fax 855-637-2666.   To request a pre-service organization determination for Summit Health MA members, please call 844-931-1778 or fax 855-637-2666.

Naloxone The FDA released a Drug Safety Communication in July 2020 recommending that healthcare professionals discuss naloxone with all patients when prescribing opioids or medicines to treat opioid use disorder (OUD).1 This update is due to the rising prevalence of OUD and overdose involving prescription and illicit opioid use.2 Patients at an increased risk for opioid overdose include individuals with a history of OUD or with a previous opioid overdose. Use of other medications and certain disease states can also increase the risk of opioid overdose. These include concurrent use of respiratory depressants (e.g., benzodiazepines), daily opioid doses exceeding 90mg morphine equivalent, comorbid renal function, etc.3   See the table below for the high-value naloxone products to use when prescribing naloxone with max refills.

Product

Quantity

Intramuscular Naloxone HCl Injection Solution (0.4mg/mL)

Two (or more) 1mL single-dose vials 3mL syringes with 23G or 25G, 1.5” needles (to match number of vials dispensed)

Narcan® (naloxone hcl) Nasal Spray (4mg/0.1mL)

Two (or more) Narcan 4mg nasal sprays

LifEMS Naloxone Kit (2mg/2mL)**

Two (or more) LifEMS Naloxone kits

**Limitations for coverage may apply, such as step therapy through high-value alternatives

Once you’ve ordered a naloxone formulation, please make sure the patient knows how to use it. It’s important to educate caregivers and family members about the symptoms of opioid overdose, how to test for consciousness, and how to administer the preferred naloxone product. Questions? You can learn more about naloxone at cdc.gov/drugoverdose/prevention/reverse-od.html. Or, call our pharmacy customer service team toll-free at 888-361-1610.

References: 1.       Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. Available at: http://wonder.cdc.gov. 2.       U.S. Food & Drug Administration. FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder. Drug Safety Communication. Available from: https://www.fda.gov/media/140360/download 3.       College of Psychiatric & Neurologic Pharmacists (CPNP). Naloxone Access: A Practical Guideline for Pharmacists. 20 Feb 2015. Available from: https://www.oregon.gov/pharmacy/Documents/Naloxone_Access.pdf

Medication Use Evaluation (MUE) Summary Thank you for caring for our members. Our Medication Use Evaluation (MUE) program allows us to find ways to improve prescription-drug use and the health outcomes of our members. This quarter, our MUEs are focused on improving adherence to recommended therapy in two different disease states. As you know, studies show that an adherence rate of less than 80% is associated with poorer health outcomes.   Recent evidence shows that certain antidiabetic medications have proven to reduce the risk of cardiovascular complications. These medications include Jardiance (empagliflozin), Farxiga (dapagliflozin), Trulicity (dulaglutide), Ozempic (semaglutide) and Victoza (liraglutide). Patients who adhere to these medications optimize glycemic control and minimize cardiovascular related complications.   For patients who have suffered a myocardial infarction (MI), beta blockers are the standard of care for secondary prevention. Those who adhere to beta blockers reduce their risk of recurrent MI and hospitalization. But, nonadherence is common due to side effects. This leads to a high rate of rehospitalization.   If you care for a Moda Health member who meets the criteria for nonadherence, you will be receive a more detailed letter soon. Please consider discussing these tips with all patients to help them remember to take their medication(s): Consider a three-month supply Add a reminder to a daily planner or calendar Set an alarm on a phone or watch Leave reminder notes Use a day-of-the-week pill box   Questions? Please call our Moda Health Pharmacy Customer Service team at 888-361-1610.

Reimbursement Policy Updates

Policy

Reason for review

Summary of update

Reviewed in April, 2021

RPM072, “Supply Limits For Ongoing Medical Supplies.”

New policy

This is a new policy in response to only finding CMS guidelines of shipping quantities for specific diabetic supply codes. Those guidelines found have been matched. Those principles are applied more generally to all ongoing medical supplies and all lines of business to match or exceed known CMS guidelines.

RPM052, “Telehealth And Telemedicine Services.”

Code clarifications, updated CMS category 3 temporary listing process post PHE, etc.

Removed EOCCO mentions from policy, since we have more than one Oregon Medicaid plan Section E.8.b updated; Medicaid covered services include any procedure code with modifier GT listed as an allowed modifier on the OHA Behavioral Health fee schedule in any Service Type category. URL link to BH fee schedule included. Intra-document navigational links added for LOB Added section D.2.c.i with CMS rural location requirement (previously missing) Added statement to section B.4.a.2) indicating using more than one telemedicine modifier per line item will result in a denial for inappropriate combination of modifiers. Use one only. Added section D.3.** with PHE impacts and what will happen to the temporarily added TH codes when the PHE ends (source: Added # 18 & 19 to Bibliography section.)

Policy

Reason for review

Summary of update

Updated Important Statement section to new wording approved 12/9/2020 Minor outline formatting changes and fixes

RPM021, “Medical, Surgical, and Routine Supplies (including but not limited to 99070)”

Annual review

Removed EOCCO mentions from policy, since we have more than one Oregon Medicaid plan Updated Important Statement section to new wording approved 12/9/2020 Changed format of Outline level A, B, C from underlined to Bold Cross References section — added # B (RPM043) & # D (RPM074) Minor grammar changes No content changes

RPM025, “Add-on Codes”

Annual review

Converted to outline format Removed EOCCO mentions from policy, since we have more than one Oregon Medicaid plan Added “An add-on code is considered a “child” code that may not be reported on a claim alone. The add-on code must be directly accompanied by a “parent” code to which it is matched or assigned.” Changed ‘primary/”parent” code’ to ‘”parent”/primary code’ per Ashley’s suggestion to keep quotation marks pointing at “parent” when the slash between words is used Changed ‘add-on code’ to ‘add-on “child” codes’ in many places to reinforce the concept of “parent” and “child” codes Replaced deleted codes G0290 & G0291 with current codes G0246 & G0247 in the Background Information examples Updated Important Statement section to new wording approved 12/9/2020 Other minor grammar and formatting changes

Reviewed in May, 2021

RPM024, “Modifier SL - State Supplied Vaccine.”

Annual review

Revised outline numbering Removed EOCCO mentions from policy, since we have more than one Oregon Medicaid plan Added header row to Modifier Definition table Updated Important Statement section to wording approved 12/9/2021

Policy

Reason for review

Summary of update

RPM050, “Risk Adjustment/HCC Coding and Documentation.”

Annual review

Converted to outline format Removed EOCCO mentions from policy, since we have more than one Oregon Medicaid plan Added A.2. new Section A.4 – added “and federally mandated RADV reviews” Section B.2 – added “and HHS-HCC” Moved “Medical record documentation for the encounter dictates what code is assigned. Coders are not permitted to assume any diagnosis.” from section A to section B. Revised wording for Section C header Removed redundant wording Moved Background Statement section to after References & Resources  Updated Important Statement section to new wording approved 12/9/2020

RPM063, “340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB)”

Updates for Oregon SB 1067, ORS 243.256, and ORS 243.879.

Added item A.5 to address new CES custom edit for OR SB 1067, ORS 243.256, ORS 243.879

RPM065, “Facility Guidelines, General Overview.”

Annual review

Removed EOCCO mentions from policy, since we have more than one Oregon Medicaid plan Added footnotes and other "for more information" statements to note where more detailed RPMs are available to expand upon overview statements in this policy Section S – added footnote to # 15 Added section U, Emergency Services Definition of Terms table – added: Level of Care with footnote Emergency Department with footnote Emergency Medical Condition with footnote Emergency Services with footnote Cross References section — added 9 new policy cross references, fixed formatting of two previously listed cross references References & Resources — added #12, 13, 14, & 15 Important Statement — updated to wording approved 12/9/2020

RPM067, “Level of Care Review.”

Annual review

Section B.3 — changed “judgement” to “determination” Section F.1 — added footnote for Noridian Definition of Terms table — added “Level of Care” References & Resources — added # 11 & # 12 Important Statement — updated to wording approved 12/9/2020

Policy

Reason for review

Summary of update

RPM068, “Readmissions.”

Annual review

Removed EOCCO mentions from policy, as we have another Oregon Medicaid plan now References & Resources section — added # 4. (Source of CMS Readmissions guidelines) Important Statement — updated to wording approved 12/9/2020

RPM069, “Facility DRG Validation.”

Annual review

Removed EOCCO mentions from policy, as we have another Oregon Medicaid plan now Definition of Terms table — added “DRG Validation” References & Resources section — added # 5 Important Statement — updated to wording approved 12/9/2020

RPM071, “Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE).”

Annual review

Removed EOCCO mentions from policy, as we have another Oregon Medicaid plan now Definition of Terms table — added footnote to Hospital-acquired condition for item a) POA Indicator table added to Codes, Terms, and Definitions section References & Resources section — added # 9 & # 10 Important Statement — updated to wording approved 12/9/2020

Medical Necessity Criteria updates

Medical necessity criteria

March 2021 summary

Pharmacy/medical

Bone growth stimulators

This is annual review, no content change

Medical

Kyphoplasty and vertebroplasty

This is annual review, no content change

Medical

Herniated disc-noncovered procedure

This is annual review, no content change

Medical

High-frequency chest wall oscillating/compression devices (HFCWO)

This is annual review, no content change

Medical

Obstructive sleep apnea-surgical treatment

This is annual review, no content change

Medical

Prostate cancer genomic assay (prolaris)

This is annual review, no content change

Medical

Treatment or removal of benign skin lesions

This is annual review, no content change

Medical

Upper extremity prostheses

This is annual review, no content change

Medical

Urinary incontinence

This is annual review, no content change

Medical

April 2021 summary

Blepharoplasty and brow ptosis repair

This is annual review, no content change

Medical

Interspinous decompression and interlaminar stabilization devices

This is annual review, no content change

Medical

Mechanical stretching devices

This is annual review, no content change

Medical

Obesity: surgical management

This is annual review, no content change

Medical

SERPINA 1 (Alpha-1-antitrypsin (A1A) genetic testing)

This is annual review, no content change

Medical

Surgical treatment of achalasia

This is annual review, no content change

Medical

Ultrasound bone density

This is annual review, no content change

Medical

Contact us

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].

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