Encourage preventive care with your Medicare patients

We know that primary care plays a key role in improving and maintaining the overall health of our members. Unfortunately, the COVID-19 pandemic resulted in many Medicare patients putting off their preventive visits, such as their Annual Wellness Visits (AWV) and Annual Physical Exams.
Please join us in encouraging your Medicare patients to complete their AWV or Annual Physical Exam to stay up to date with their preventive care.
Your Moda Health Medicare Advantage and Summit Health patients have a covered AWV and an Annual Physical Exam once every calendar year at no cost. While these visits are not Medicare Star Measures, they are important opportunities to impact many quality measures and improve better health outcomes for your patients.
These also allow opportunities to evaluate and discuss health topics that are included in the annual CMS Health Outcomes Survey (HOS) that takes place from July through November, and include:
  • Monitoring physical activity
  • Improving bladder control
  • Reducing the risk of falling
An AWV and the Annual Physical Exam can be completed at the same visit. They can also be combined with a problem visit, but please note that a cost-share would apply if combined with a problem visit.
Be sure to explain any additional services that may be performed during a visit so that your patients understand their expected out-of-pocket costs.
Support for capturing data and closing care gaps
This summer, Moda Health Medicare Advantage will be implementing a web-based Care Gap Management Application (CGMA) by Novillus. a leader in data-driven provider engagement solutions.
The CGMA will provide:
  • Two-way clinical data exchange
  • Workflow improvements for your clinic staff to easily upload charts year-round for Hierarchical Condition Categories (HCC) capture and care gap closure for both Medicare Star Measures and risk adjustment. This will help ease the year-end administrative burden for chart requests.
  • Ability to track and manage quality performance and incentive earnings on the Medicare Advantage Primary Care Incentive Program (MAPCIP)
  • Ongoing provider coding and documentation education by Novillus
Our goal in implementing the CGMA is to provide a valuable and easy-to-use tool for our clinic partners to capture HCCs and close care gaps. We know that many clinics may already be using this CGMA. With this in mind, our implementation strategy will be tailored to your clinic’s specific needs.
Stay tuned. We plan to roll out more information about this in the next few months.
Kidney care for your patients

In this time of unprecedented health system constraints, we’ve partnered with
Strive Health to support you in providing kidney health management to your Moda Health Medicare Advantage, Summit Health, and Commercial OEBB and PEBB patients.
This program supports patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) by providing a continuum of care management and direct clinical care to help patients as their disease progresses.
Kidney care sometimes focuses on dialysis alone after a patient’s health has deteriorated. Strive’s goal is to engage patients with CKD stage 3 to 5 or ESRD. The program serves as an extension of your practice by managing patients early and throughout their entire kidney care journey, aligned with each patient’s individual needs. Early identification and high-touch engagement result in:
  • Improved health outcomes
  • A more simplified patient experience
  • Lower healthcare costs
Strive routinely engages participants to support their overall health and well-being in-person, by phone, and through other channels. Patients receive education about their condition and treatment options for condition management, and are engaged in care planning activities. This includes information about:
  • Dialysis center treatments
  • In-home dialysis
  • Kidney transplant options
Care plans are customized to fit each patient’s needs and preferences. 

We’re here to help! To learn more, email Strive Health’s Lisa Dietz at ldietz@strivehealth.com
The basics and benefits of biosimilars

Biological medications (or biologics) are a fast-growing medication class. They play an important role in improving patient outcomes for several diseases. Similar to how traditional generic medications may reduce cost and improve patient access to care compared to brand medications, biosimilars have emerged as an alternative to biologics.
Below, we’ve provided a brief Q&A to help you better understand what biosimilars are, how they work, and how they are tested and approved. If you have any questions, please call our Moda Health Pharmacy Customer Service team at 888-361-1610.
What is a biosimilar?
According to the FDA, a biosimilar is a biologic that has a highly similar structure and function to an FDA-approved biologic, otherwise known as a reference product. Common examples include Nivestym (reference product: Neupogen), Renflexis (Rituxan) and Mvasi (Avastin).
How are biosimilars different than generic drugs?
Brand and generic small-molecule drugs contain the same chemical entity. Conversely, biologics are large and complex molecules that are created from living cells. It is the nature of biologics to have inherent variability, even among manufactured lots of the same biologic. Despite this variability and complexity, biologics have consistent safety and efficacy. Therefore, biosimilars must demonstrate that they are highly similar to the reference product.
How are biosimilars tested and approved?
All FDA-approved biosimilars must undergo a rigorous testing process to compare safety, purity and potency between the proposed biosimilar and the reference product to ensure there are no meaningful clinically differences. Only minor differences between the products are allowed, such as in clinically inactive components.
Are biosimilars approved for all the same indications as the reference product?
Biosimilars may be approved for all or a subset of indications for the reference product. It is common for a biosimilar to have fewer indications if the reference product has remaining patent or exclusivity rights.
Providers and patients can expect that biosimilar products will have the same clinical efficacy and safety profile as the brand biologic product due to thorough testing by the FDA to meet high standards for approval. Moda Health’s goal is to increase patient access to high-quality, cost-effective care. Biosimilars may fill this unmet need as a more affordable alternative to brand biologic therapies.
As always, we appreciate your support in helping our members to better health and wellness.

1. U.S. Food and Drug Administration. Biosimilars – Healthcare provider materials. Updated July 28, 2021. Accessed April 22, 2022. https://www.fda.gov/drugs/biosimilars/health-care-provider-materials?utm_campaign=cder-factsheets&utm_content=&utm_medium=social&utm_source=linkedin
2. Biologics and Biosimilars Collective Intelligence Consortium. Biosimilar facts. Accessed April 22, 2022. https://www.bbcic.org/resources/biosimilars-facts
3. U.S. Food and Drug Administration. Purple book: Database of licensed biological products. Updated April 4, 2022. Accessed April 22, 2022. https://purplebooksearch.fda.gov/
Improving the efficacy of member therapies 

Our Medication Use Evaluation (MUE) program allows us to continually look for ways to improve prescription-drug use and health outcomes of our members. In Q2, we conducted an MUE that focused on improving adherence to antidepressant therapy.
As you know, studies show that an adherence rate of less than 80% is associated with poorer health outcomes leading to decreased quality of life. Risk factors for non-adherence in patients with depression include age, comorbid conditions, belief in treatment, fear of stigma and inadequate patient education.1,2 In addition to traditional adherence improvement techniques, recent studies have found that shared decision making between provider and patient when creating an antidepressant treatment plan is associated with improved adherence.3
Discussing the following tips with all patients may help them remember to take their medication(s) as prescribed:
  • Consider filling a three-month supply, if appropriate
  • Add a reminder to your daily planner or calendar
  • Set an alarm on your phone or watch
  • Leave reminder notes
  • Use a day-of-the-week pill box
A second MUE focusing on the initiation of urate lowering therapy (ULT), including allopurinol (Zyloprim), febuxostat (Uloric) and probenecid (Probalan), in gout patients who have only been treated with colchicine, was also conducted this quarter. The 2020 American College of Rheumatology guidelines recommend using ULT, with or without colchicine, to prevent recurring gout attacks. Furthermore, guidelines recommend titrating ULT dose to achieve and maintain a serum urate level of <6mg/dL.4
If you care for a Moda member who meets the criteria for inclusion in one or more of the MUEs described above, you will soon be receiving a more detailed letter.
As always, we thank you for your continued support in helping our members to better health and overall wellness.

1.   Sirey JA, et al. Adherence to Depression Treatment in Primary Care: A randomized clinical trial. JAMA Psychiatry. 2017;74(11):1129-1135.
2.   Tamburrino MB, et al. Antidepressant Medication Adherence: A Study of Primary Care Patients. Prim Care Companion J Clin Psychiatry. 2009;11(5).
3.   Lin EHB, Von Korff M, Ludman EJ, et al. Enhancing adherence to prevent depression relapse in primary care. Gen Hosp Psychiatry. 2003; 25(5):303–310.
FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research. June 2020;72(6):744-760.
Reimbursement Policy Updates

The following table includes RPM updates for April and May 2022.
Summary of update
Reviewed in April 2022
None. Committee meeting cancelled.
Reviewed in May 2022
RPM058, “Behavioral Health Case Management & Care Coordination”
  • Scope – Added Alaska. Added Texas effective DOS 10/1/2022
  • Reimbursement – H0038 accepted & separately allowed effective 1/1/2022. Clarified status of 99495, 99496, and H2023. Removed deleted codes G0502, G0503, G0504, G0505, G0507 but left in Codes, Terms and Definitions section with shortened to save space. Listings left in place for this first update as a help to identify effective/termination dates & replacement codes. Added G2214 (new 1/1/2021).
  • Policy History section – Added
Annual Review, with changes
RPM006, “Robotic Assisted Surgery”
  • Scope – Added Medicare, Medicaid & Summit Health
  • Minor rewording, no policy changes
  • Acronym table – Added
  • Definition of terms table – Added
  • References & Resources – # 4 added
  • Background information – Quote from OHA (for Medicaid) added as paragraph 2
  • Policy History – Added
Annual Review, with clarification, no policy changes
RPM003, “Modifier 52 - Reduced Services”
  • Added additional clarification & examples of incorrect use of modifier 52. Supporting quote added to Coding Guidelines section & # 12 added to References & Resources.
  • Acronym Table – 7 entries added
  • Definition of terms – Added
  • Policy History – Added
RPM018, “Modifier 53 – Discontinued Procedure”
  • Added additional clarification & examples of inappropriate use of modifier 53
  • Coding guidelines – Added quote from CCI PM Chapter 1, section L.6
  • Cross references – Added RPM007
  • References & Resources – Added # 14 - 17
RPM049, “Modifiers 73 & 74 - Discontinued Procedures for Facilities”
  • Clarified limits for discontinued modifiers and appropriate/inappropriate usage
  • Acronyms – 7 added
  • Policy History – Added
RPM065, “Facility Guidelines, General Overview”
  • Scope – Added Summit Health
  • Added information about special care unit LOS reviews. These have been occurring (concurrent, pre-pay, post-pay) but were not previously mentioned in the policy.
  • Acronym table – Added 1
  • Policy History – Added
RPM067, “Level of Care Review”
  • Scope – Added Summit Health
  • Added information about special care unit LOS reviews. These have been occurring (concurrent, pre-pay, post-pay) but were not previously mentioned in the policy.
  • Acronym table – Added 11
  • Policy History – Added
Medical Necessity Criteria updates

Medical criteria changes March and April 2022.
Medical Criteria Summary
Bone growth stimulators – Electric
Introduction: This is an annual review
Criteria changes: No changes
Herniated disc-noncovered procedures
Introduction: This is an annual review
Criteria changes: No changes

High-frequency chest wall oscillating devices
Introduction: This is an annual review
Criteria changes: No changes
Interspinous decompression and interlaminar stabilization devices
Introduction: This is an annual review
Criteria changes: No changes
Alpha-1 – Antitrypsin deficiency genetic testing (Serpina 1)

Introduction: This is an annual review
Criteria changes: Title updated, no change in wording
Treatment or removal of benign skin lesions
Introduction: This is an annual review
Criteria changes: No changes
Upper extremity prostheses
Introduction: This is an annual review
Criteria changes: No changes
Urinary incontinence
Introduction: This is an annual review
Criteria changes: No changes
April Medical Criteria Summary
Blepharoplasty and brow ptosis repair
Introduction: This is an annual review
Criteria changes: No changes
Leveling of emergency room services
Introduction: This is an annual review
Criteria changes: An intermittent update where ED levelling was expanded to facility claim. Facility bills would be reimbursed at an indicated reimbursement rate.
Electrical stimulation devices
Introduction: This is an annual review
Criteria changes: Minor grammar updates
Hyperbaric oxygen therapy
Introduction: This is an annual review
Criteria changes: No changes
Intraoperative neurophysiologic monitoring
Introduction: This is an annual review
Criteria changes: No changes
Mechanical stretching devices
Introduction: This is an annual review
Criteria changes: No changes
Obesity surgical management
Introduction: This is an annual review
Criteria changes: No changes
Surgical treatment of achalasia
Introduction: This is an annual review
Criteria changes: No changes
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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