In this issue
- Colorectal screening kits
- Reimbursement Policy updates
- Medical Necessity Criteria updates
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Join our email list
Join our email list in order to begin receiving bi-monthly newsletters, as well as occasional electronic communications.
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Sign up for our 2021 fall
provider workshop
Keeping up with the latest healthcare changes is how we can help build and support healthy communities. Join us at our 2021 fall virtual workshops to learn about our 2021 updates and get a glimpse of what's ahead for 2022.
Our provider workshops will be held virtually. They will cover the following specialties and topics:
- Primary care
- Alternative care
- Behavioral health
- Billing
- Alaska
- Texas
How to register
Visit our website to register. Space is limited, so please RSVP as soon as possible.
Questions?
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Magellan Rx enhancing provider portal
The Magellan Rx website is getting a makeover. In August, changes will be made to make the provider login process more secure and seamless. The updates will make it easy to view and request medical pharmacy prior authorizations, and download the forms, tools and information that you need.
What you need to know
- The current site you use will redirect you to the new platform.
- Your username will be your email address. Magellan Rx will send a confirmation of your temporary password before the August launch.
- Once you are logged in, you can complete prior authorization activities through the web-based planform the same way you do today.
- Magellan Rx will send reminders to you before the August launch.
What you need to do
To prepare for this transition, it’s important that your email address is correct for Magellan to send you information about this change. Please take the following steps to verify your current email address.
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Log in to the provider portal at magellanrx.com
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Under My Profile, select Edit My Profile to confirm the accuracy of your email address
- Update the email address if it is not current
Questions?
We’re here to help. If you have any questions, please email us at MRxPR@MagellanHealth.com. To learn more, see the Provider Portal Login FAQ.
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Colorectal cancer screening kits being
mailed to your Medicare patients
Please join us in encouraging your patients to complete their colorectal cancer screening. Improving the number of patients who complete this screening impacts the Medicare Star Measure.
Moda Health and Summit Health are partnering with BioIQ (a leader in health and wellness engagement) to mail at-home, non-invasive Fecal Immunochemical Test (FIT) kits to your Medicare Advantage patients, at no cost to them.
The U.S. Preventive Services Task Force recommends regular colorectal cancer screening starting at age 45. The FIT is a simple and convenient way to screen for the presence of blood in stool to proactively identify colon cancer. Eligibility for our FIT campaign is determined by age and medical claims information.
In September, BioIQ will mail your eligible patients a program announcement letter, followed by a FIT kit directly to their home. When your patients receive the kit, they should follow the directions to complete and return the kit to BioIQ. The results of the screening will be sent to you and your patients. If your patients’ results are positive or abnormal, BioIQ will conduct additional outreach to your patients to ensure they understand their results and schedule a follow-up appointment with you to discuss further actions, as appropriate.
We want to support your patients with closing their care gap, making this task as easy as possible. And we ask that you encourage your patients to take advantage of this no cost FIT campaign.
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Care guide reminders to help close your patients' care gaps
Moda Health and Summit Health are sending our third-quarter care guide reminders to educate and help your Medicare Advantage patients schedule their recommended preventive services. This is a follow-up to the initial outreach conducted in the second quarter to help close any remaining care gaps.
We ask that you work with your patients on their open care gaps and complete those that are appropriate for their overall health management.
In August, our highly trained health advocates will be calling 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
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Reimbursement Policy Updates
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RPM026, “Operating Microscope (CPT Code 69990)”
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- Removed EOCCO from document because Moda now has more than one Medicaid group
- Second paragraph, first bullet point, additional wording added
- 2nd paragraph, 2nd and 3rd bullet points, existing content converted to bulleted list
- Important Statement section wording updated
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RPM039, “Medical Records Documentation Standards.”
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- Removed EOCCO mentions from document because Moda now has more than one Medicaid group
- Converted to outline format
- Important Statement section wording updated
- Minor punctuation, wording and grammar updates
- No content changes
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RPM049, “Modifiers 73 & 74 - Discontinued Procedures For Facilities.”
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- Removed EOCCO mentions from document because Moda now has more than one Medicaid group
- Section E simplified to reference back to RPM003 Modifier 52
- References & Resources # 3 added
- Important Statement section wording updated
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RPM061, “Clinic Services In the Hospital Outpatient Setting - Commercial.”
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- Removed EOCCO mentions from document because Moda now has more than one Medicaid group
- Converted to outline format
- Background Information section relocated
- Important Statement section wording updated
- No content changes
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RPM064, “Modifiers PO & PN - G0463 Clinic Visit Services at Excepted Off-Campus Provider-Based Outpatient Department - Medicare Advantage.”
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Annual review and provider appeals
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- Section A.1 revised
- Important Statement section wording updated
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RPM070, “Modifier SU - Procedure Performed in Physician’s Office
(Facility and equipment).”
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- Removed EOCCO mentions from document as Moda now has more than one Medicaid group
- Scope section — Minor grammar fix with aka
- Important Statement section wording update
- No content changes
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RPM007, “Modifier 22 – Increased Procedural Services.”
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- Removed EOCCO mentions from document because Moda now has more than one Medicaid group
- Added acronyms table
- Cross References section — Added # C and used as footnote.
- References & Resources section — Added # 17 and 18, and used as footnotes
- Important Statement section wording updated
- Minor format changes. No content changes.
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RPM009, “Postoperative Sinus Debridement Procedures.”
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- Removed reference to EOCCO because Moda now has more than one Medicaid plan
- Important Statement section wording updated
- Minor grammar, spacing and formatting updates. No content changes.
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RPM028, “Modifier 25 – Significant, Separately Identifiable E/M Service.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Converted to outline format
- Section E.1.a.iii added to clarify multiple preventive visits allowed for Medicare Advantage members
- Acronym table added
- Important Statement section wording updated
- Minor grammar and punctuation changes. Fixed font size to be consistent.
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RPM030, “Modifiers 54, 55, and 56 – Split Surgical Care.”
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- Section B — Added clarifying information that the same procedure code and date of service is to be billed by both physicians when modifiers 54 and 55 are used
- Important Statement section wording updated
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RPM031, “Modifier 47 - Anesthesia by Surgeon.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Acronym table added
- Important Statement section wording updated
- Minor grammar, spacing and formatting updates
- No content changes
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RPM033, “Qualifying Circumstances for Anesthesia.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Acronym table added
- Important Statement section wording updated
- Minor grammar, spacing and formatting updates
- No content changes
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RPM024, “Modifier SL -
State Supplied Vaccine.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Acronym table — Added AMA, TAVI, TAVR
- Important Statement section wording updated
- Minor grammar, punctuation and line spacing changes
- No content changes
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RPM036, “Modifiers GA,
GX, GY, and GZ.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Changed order of lines of business in Reimbursement Guidelines section to match listing in Scope and be consistent with other policies
- Acronym table added
- Important Statement wording updated
- Minor punctuation and formatting changes
- No content changes
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RPM038, “Computer
Assisted Navigation.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Acronym table added
- Important Statement wording updated
- Minor line spacing changes
- No content changes
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RPM042, “Revenue Codes Ending in "9" ("Other" Categories)”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Acronym table added
- Important Statement wording updated
- No content changes
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RPM043, “Hospital Routine Supplies and Services.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Section B.2.a — Footnotes added to 5th bullet, bladder scans added, rectal inserts added with footnote
- Coding & Billing Guidelines section —
- Relocated to after Codes, Terms & Definitions
- Added another guideline quote to section
- Acronym table added
- Important Statement section wording updated
- Minor line spacing, format and grammar updates
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RPM047, “Facility Reimbursement of Respiratory Therapy Services.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Converted Reimbursement Guidelines to outline format
- Section E — Revised wording and added #34, 49
- Acronym table added multiple listings
- Important Statement section wording updated
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RPM059, “Radiology Reductions for Technology
Type - Modifiers FX and FY.”
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- Removed references to EOCCO because Moda now has more than one Medicaid plan
- Acronym table added multiple listings
- Important Statement section wording updated
- Minor line spacing and format updates
- No content changes
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RPM066, “DRG Payment
with Patient Transfers.”
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- Removed EOCCO from document because Moda now has more than one Medicaid group
- Scope section — Specified “acute-care” hospitals
- Purpose section — Reworded
- Section B.1.b. Revised Section D.2 minor clarification added
- Definitions of Terms table — Added Allowable Amount. Revised listings for Discharge, Transfer reworded to “Transfer, acute care”
- Discharge Status codes table — Added multiple listings References & Resources section — Added # 10, 11 and 12
- Important Statement section — Wording updated
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Medical criteria changes May/June 2021
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This is an annual review. There were no content changes.
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Continuous Glucose Monitoring
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This is an annual review. Removed contradicting language from description section.
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Electrical Devices for Home Use
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This is annual review. Added Transcutaneous Electrical Nerve Stimulation (TENS) diagnosis and devices that are considered experimental and investigational.
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Hyperbaric Oxygen Therapy
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This is an annual review. There were no content changes.
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Intraoperative
Neurophysiologic Monitoring
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This is an annual review. There were no content changes.
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This is an annual review. There were no content changes.
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This is an annual review. There were no content changes.
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Intervertebral Disc Prosthesis
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This is an annual review. There were no content changes.
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Spinal Cord Stimulators
(Dorsal Column Stimulators)
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This is an annual review. There were no content changes.
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This is an annual review. There were no content changes.
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This is an annual review. There were no content changes.
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Anodyne Therapy
(Monochromatic Infrared Energy)
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This is an annual review. There were no content changes.
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Corneal Collagen Cross-Linking
for Treatment of Keratoconus
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This is an annual review. There were no content changes.
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Temporomandibular Joint (TMJ)
Non-Surgical Treatment
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This is an annual review. There were no content changes.
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This is an annual review. There were no content changes.
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Moda 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
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Provider Updates
Credentialing Department
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Copyright © 2021. All Rights Reserved.
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