In this issue
- Credentialing with Moda-CAQH
- New Partnership announcement for Infusion and Enteral Therapies
- Moda Health Medicare Advantage Provider Manual
- Closing the gap on well-child visits
- Colorectal cancer screening update
- Encourage your patients to take the member experience survey
- Capture patient data and close care gaps year-round
- DME Moda Health Medicare Advantage and Summit Health
- Medical Pharmacy Prior Authorization
- Reimbursement Policy updates
- Medical Necessity updates
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Moda Health workshops Fall 2022
Keeping up with the latest healthcare changes is how we can help build and support healthy communities. Join us to learn about our 2022 updates and get a glimpse of what's ahead for 2023! This fall our workshops will be held virtually and are broken out by the following specialties/topics:
- Primary Care
- Behavioral Health
- Billing
- Alaska
- Texas
We're here to help. Just call us toll-free
TTY users, please call 711.
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Credentialing with Moda-CAQH
We are pleased to announce that Moda now utilizes the CAQH ProView site as an application source.
If you would like Moda to initiate the credentialing process utilizing this product, please send the provider's first name, last name, and CAQH ID to Credentialing@modahealth.com.
For our currently credentialed providers, CAQH Proview will also be used to obtain recredentialing applications. If a recredentialing request is received by mail, we were not able to access a current application through CAQH.
Important note: CAQH must reflect that Moda has permission to access this application. The application must be up to date with current attestation status to allow the application to be used. Outdated, or incomplete applications will not be accepted or processed.
You may contact the credentialing team with questions at any time by phone or email. We are always happy to assist.
Toll-free phone number: 855-801-2993
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New Partnership announcement for Infusion and Enteral Therapies
We are excited to announce a new partnership between Emerging Health
and Moda Health!
Emerging Health is a new, locally owned, and operated home infusion
and ambulatory infusion center located in Southwest Portland.
Emerging Health offers the following services and therapies:
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Home Infusion: Patients can receive treatment in the comfort of their homes. Personalized care options give patients freedom that fits their lifestyle.
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Ambulatory Infusion Center (AIC): The ambulatory facility 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.
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Enteral Therapy: Local 1:1 education, monitoring, and assessments from board-certified nutrition support clinicians for tube-fed patients.
The Emerging Health Difference
Emerging Health strives to exceed expectations and ensure patients and their caregivers have positive and thoughtfully coordinated experiences. They view their service as an extension of the care you and your staff provide.
- Emerging Health 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 learn more, place a referral or arrange for a tour of our facility,
please call 877-290-2040.
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Newly revised Medicare Advantage provider manual
Questions?
For questions about our Medicare Advantage provider manual, please email us at ebt@modahealth.com.
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Closing the gap on well-child visits
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) is a very important component of a well-child checkup. We want to help you close the HEDIS gaps during your child or adolescent visits. You can do this by either:
- Documenting in the medical record, and/or
- Using specific ICD10 diagnosis codes on claims. This can reduce the need to provide medical records during the HEDIS season.
What is WCC?
The percentage of members between 3 and 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year.
- BMI Percentile Documentation*
- Counseling for Nutrition
- Counseling for Physical Activity
*Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. Please do not chart absolute BMI value.
BMI percentile documentation
Documentation in the medical record must include height, weight and BMI percentile during the measurement year. All data must be from the same data source.
Either of the following meets criteria for BMI percentile:
- BMI percentile documented as a value (e.g., 85th percentile)
- BMI percentile plotted on an age-growth chart. The chart must be included in medical record.
ICD10 codes may also be submitted via claim. This can eliminate the need for Moda to request charts for validation on this measure during the HEDIS season. Below are the ICD10 codes that will close this gap via claims:
- [Z68.51] Body mass index [BMI] pediatric, less than 5th percentile for age
- [Z68.52] Body mass index [BMI] pediatric, 5th percentile to less than 85th percentile for age
- [Z68.53] Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age
- [Z68.54] Body mass index [BMI] pediatric, greater than or equal to 95th percentile for age
Counseling for nutrition
Documentation must include a note indicating the date and at least one of the following:
- Discussion of current nutrition behaviors (e.g., eating habits, dieting behaviors)
- Checklist indicating nutrition was addressed
- Counseling or referral for nutrition education
- Member received educational materials on nutrition during a face-to-face visit
- Anticipatory guidance for nutrition
- Weight or obesity counseling
ICD10 codes may also be submitted via claim. This can eliminate the need for Moda to request charts for validation on this measure during the HEDIS season. Below is the ICD10 code that will close this gap via claims:
- [Z71.3] Dietary counseling and surveillance
Counseling for physical activity
Documentation must include a note indicating the date and at least one of the following:
- Discussion of current physical activity behaviors (e.g., exercise routine, participation in sports activities, exam for sports participation)
- Checklist indicating physical activity was addressed
- Counseling or referral for physical activity
- Member received educational materials on physical activity during a face-to-face visit
- Anticipatory guidance specific to the child’s physical activity
- Weight or obesity counseling
ICD10 codes may also be submitted via claim, which can eliminate the need for Moda to request charts for validation on this measure during the HEDIS season. Below are the ICD10 codes that will close this gap via claims:
- [Z71.82] Exercise counseling
- [Z02.5] Encounter for examination for participation in sport
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Colorectal cancer screening update
In March, the National Committee for Quality Assurance (NCQA) announced updates to their Healthcare Effectiveness Data and Information Set (HEDIS) technical specifications for Measurement Year 2022. The changes included lowering the age range for the Colorectal Cancer Screening measure from ages 50 to 75 years to ages 45 to 75.
For the 2022 Medicare Advantage Primary Care Incentive Program (MAPCIP), the quality measure will be updated to reflect the lowered age range to align with HEDIS tech specs and CMS Medicare Preventive Guidelines.
Summit Health has also updated our member benefits for colorectal cancer screening services to address the lowered age range. Note that the (*) indicates if a service meets numerator compliance for HEDIS.
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Updated colorectal cancer screening benefits
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Age: 45 – 75
Frequency: 5 years
Cost share will apply since this is not a preventive screening and requires medical review
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Guaiac-based fecal occult blood test (gFOBT) |
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Age: 45+
Frequency: Once per calendar year
No cost share with in-network provider.
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DNA based colorectal screening* |
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Age: 45+
Frequency: 3 years
No cost share with in-network provider.
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Low risk
Age: 50+
Frequency: Once every 4 years
High risk
Age: No age minimum or limit
Frequency: Once every 2 years
No cost share with in-network provider.
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Age: No minimum or limit
Frequency: Low risk (based on CPT) every 10 years; and high risk (based on CPT) every 2 years
No cost share with in-network provider.
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Screening flexible sigmoidoscopy* |
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Age: 45+
Frequency: 4 years
No cost share with in-network provider.
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Age: 45+
Frequency: Once per calendar year
No cost share with in-network provider.
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Encourage your patients to take the member experience survey
The Centers for Medicare and Medicaid Services has made the member and patient experience a top priority with CAHPS survey measures now making up 33% of the Star Ratings calculations for Medicare Advantage. These Star Measures include rating the experience with the health and drug plan, health care quality, and access to care and care coordination between providers.
Moda Health Medicare Advantage and Summit Health are committed to providing great member experience and continual improvement. One of the ways we are doing this is by partnering with Symphony Performance Health (SPH) Analytics to conduct a mock CAHPS survey with a sample of our Moda Health Medicare Advantage and Summit Health members in August. This survey will help us collect member feedback we can use to make improvements to the overall member experience.
As our valued partner, we ask that you encourage your patients to respond to the survey if they are randomly selected in the sample. This way, we can share aggregate data with you at the end of this outreach. Many of your patients may receive the 2023 Medicare CAHPS, and the interactions you have with them and their perception will directly impact CAHPS Star Measure Ratings.
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Capture patient data and close care gaps year-round
To support our Moda Health and Summit Health Medicare Advantage Primary Care Incentive Program (MAPCIP), we will soon be implementing a web-based Care Gap Management Application (CGMA) by Novillus. This tool will allow our clinic partners to view and close care gaps, capture Hierarchical Condition Codes (HCCs), manage your patient roster, and view your process in the incentive program throughout the year.
Our goal is to provide a valuable and easy-to-use tool for your clinical team to capture HCCs and close care gaps. By providing efficient two-way data exchange, the Novillus application allows your staff to:
- Easily upload charts for HCC capture and care gap closure for both Medicare Star Measures and risk adjustment. This helps remove the administrative burden for chart requests at the end of the year.
- Track and manage quality performance and incentive earnings on the MAPCIP
- Receive ongoing provider coding and documentation education
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Prior authorization removed for $250+ DME
For Moda Health Medicare Advantage and Summit Health members, we have removed the prior authorization requirement for Durable Medical Equipment (DME) that costs over $250. This requirement was removed effective July 1, 2022. DME that require a prior authorization by a specific procedure code still has an authorization requirement in place.
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Medical Rx prior authorizations made easy
We partner with Magellan Rx Management to process prior authorization requests for most Moda Health members. For a more efficient and streamlined process, requests for medical pharmacy prior authorizations may be made online at the Magellan Rx Management secure, HIPAA compliant web portal MRxGateway.com.
To obtain access to the portal, visit MRxGateway.com. Under the “Sign in” box, select “New Provider Access Request” to complete and submit the request form. Magellan Rx will respond within two business days.
Questions?
We’re here to help. For any questions, please email the Magellan Rx Provider Relations team at MRxPR@MagellanHealth.com.
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Medical Rx prior authorizations made easy
Previously, we discussed how biosimilars have emerged as an alternative to biologics to reduce cost and improve patient access to care relative to brand medications. More recently, biosimilars have begun to seek interchangeable status as a way to further improve patient access to care.
Below, we’ve provided answers to some of the most commonly asked questions about biosimilars and interchangeable products.
What is an interchangeable product?
An interchangeable product is a biosimilar that may be substituted for the branded reference product. The interchangeable product must meet added requirements of the Biologics Price Competition and Innovation Act (BPCIA), which requires further evaluation and testing to show the product is expected to produce the same clinical result as the reference product in any given patient. Additionally, for products that will be administered more than once, the manufacturer must provide data to show patients can be switched back and forth between the reference product and the proposed interchangeable product without an increased risk in terms of safety or diminished efficacy. While there currently is only one interchangeable product on the market [insulin glargine-yfgn (Semglee)], more are anticipated [adalimumab-adbm (Cyltezo)].
Can interchangeable products be used in patients previously treated with the reference product?
Yes. The FDA requires rigorous testing for a biosimilar product to be labeled as interchangeable. With this testing, interchangeable products can be expected to produce highly similar clinical results when compared to the reference product.
Can interchangeable products be substituted for reference products by pharmacists?
Yes. An interchangeable product may be substituted for the reference product with or without involvement of the prescriber. However, the specific laws that address pharmacy-level substitution vary from state to state. Providers will be notified of substitution by the pharmacy as required by law. Pharmacy-level substitution is currently allowed by law in Alaska, Oregon, Texas and Washington.
Providers and patients can expect that interchangeable products will have the same clinical efficacy and safety profile as the reference product and can be substituted for the reference product at the pharmacy to promote continuity of care. It is Moda Health’s goal to increase patient access to high-quality, cost-effective care. Biosimilars and interchangeable products may fill this unmet need as a more affordable alternative to brand biologic therapies.
Questions?
We’re here to help. Please call our Moda Health Pharmacy Customer Service team
As always, we appreciate your support in helping our members to better health and wellness.
References:
- U.S. Food and Drug Administration. Interchangeable Biological Products – Healthcare provider materials. Updated July 28, 2021. Accessed April 18, 2022. https://www.fda.gov/drugs/biosimilars/health-care-provider-materials?utm_campaign=cder-factsheets&utm_content=&utm_medium=social&utm_source=linkedin
- U.S. Food and Drug Administration. Prescribing Interchangeable Products– Healthcare provider materials. Updated July 28, 2021. Accessed April 18, 2022. https://www.fda.gov/drugs/biosimilars/health-care-provider-materials?utm_campaign=cder-factsheets&utm_content=&utm_medium=social&utm_source=linkedin
- Cauchi R. National Conference of State Legislatures website. State laws and legislation related to biologic medications and substitution of biosimilars. May 3, 2019. https://www.ncsl.org/research/health/state-laws-and-legislation-related-to-biologic-medications-and-substitution-of-biosimilars.aspx. Accessed April 12, 2022.
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Reimbursement Policy Updates
The following table includes RPM updates for June and July 2022.
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- Change to new header.
- A. Important Statement: Reworded. No content changes.
- B. General Information: Clarified list of Moda Health company names.
- F.1. Sources of Policy Development: Added Novitas Solutions & CGS Administrators (MACs for Texas).
- Minor rewording to convert “Moda Health” to “our” and “we” as much as possible.
- Policy History section: Added.
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RPM075, “Emergency Department Visit Leveling” |
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- Change to new header.
- Scope: Added effective for facility claims. (Texas is excluded.)
- Acronyms: 5 entries added.
- Policy History: Added.
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Clarification, no policy changes: |
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RPM004, “After Hours and Other Special Circumstances” |
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- Change to new header.
- Procedure Code Table: “for Commercial plans” added to sub-header “Codes separately reimbursed under limited circumstances” for clarity.
- Policy History section: Added.
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RPM013, “Modifiers 80, 81, 82, and AS – Assistant at Surgery” |
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- Change to new header. Changed Subsection field from “None” to “Surgery.”
- Acronym table: 1 entry added.
- References & Resources: Item # 6 added for Texas; there is not a Novitas equivalent of the Noridian citation on RNFAs not eligible as assistant surgeon. This is the closest original CMS reference where it shows RFNA is not on the list of eligible providers for assistant surgeon services.
- Policy History section: Added.
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RPM039, “Medical Records Documentation Standards” |
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- Change to new header.
- Changed Section field from “Administrative” to “Documentation.”
- Section C.4. Added "charge capture reports."
- Acronym table: 3 entries added.
- Coding Guidelines & Sources: 3 quotes added.
- References & Resources: added # 38 - 45. Footnotes updated.
- Policy History section: Added.
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RPM044, “Gynecologic or Annual Women’s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit)” |
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- Change to new header.
- Added information for Medicare Advantage on IPPE, AWE, & annual routine (preventive) physical added benefit.
- Clarified results of reporting Pap/pelvic/breast exam visit with 99381-99397 for Medicare Advantage plans.
- Minor rewording, no policy changes.
- Acronym Table: Added 6 entries.
- Procedure code table: deleted outdated code descriptions from 2020.
- References & Resources: # 7 added.
- Background Information: Added ¶ # 3.
- Policy History section: Added.
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- Change to new header.
- Acronym Table: 7 entries added. 1 entry removed.
- Coding Guidelines: Key quote added from References & Resources entry # 1.
- Policy History section added.
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RPM076, “Office or Other Outpatient Evaluation and Management (E/M) Visits and Prolonged Services” |
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- Change to new header.
- Section A.4.c added in response to provider question.
- Acronym table: 6 entries added.
- Policy History section: Added.
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Formatting, no policy changes: |
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RPM007, “Modifier 22 – Increased Procedural Services” |
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- Change to new header.
- Change subsection from None to Surgery.
- Policy History section: Added.
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RPM034, “Modifiers AA, AD, GC, QK, QX, QY, QZ – Anesthesia Payment Modifiers” |
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- Change to new header.
- Acronym table: 1 entry added.
- Policy History section: Added.
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RPM059, “Radiology Reductions for Technology Type - Modifiers FX and FY” |
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- Change to new header.
- Acronym table: 5 entries added.
- Policy History section: Added.
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RPM060, “Transportation of Portable X-ray Equipment, Multiple Portable X-rays – Modifiers UN, UP, UQ, UR, US” |
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- Change to new header.
- Acronym table: 6 entries added; 1 entry removed.
- Coding Guidelines & Sources: Quote added from transmittal 343.
- Policy History section: Added.
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RPM066, “DRG Payment With Patient Transfers” |
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- Change to new header.
- Fixed Original Effective date
- Acronym table: Added 5 entries.
- Policy History section: Added.
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RPM069, “Facility DRG Validation” |
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- Change to new header.
- Acronym Table: 5 entries added.
- Policy History Section: Added.
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RPM071, “Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE)” |
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- Change to new header.
- Acronym table: 9 entries added.
- Policy History section: Added.
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Clarification, no policy changes: |
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RPM009, “Postoperative Sinus Debridement Procedures” |
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- Change to new header.
- Acronym Table & Definition of Terms Table: Added
- Coding Guidelines & Sources: 2 quotes added from CMS References & Resources #2.
- References & Resources: # 11 added.
- Minor rewording; no content changes.
- Policy History section: Added.
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RPM035, “Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons)” |
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- Change to new header. Changed Subsection from “None” to “Surgery.”
- Section B.6.a: Expanded to add Medicare Advantage pricing adjustment for out-of-network providers for modifier 62.
- Acronym table: 4 entries added.
- Policy History section: Added.
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RPM043, “Hospital Routine Supplies and Services” |
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- Change to new header.
- Acronym table: 2 entries added.
- Coding Guidelines & Sources: 6 additional CMS quotes added.
- References & Resources:
- Item # 9 duplicate with typo deleted, those following renumbered.
- Item # 26 updated to reflect CMS change in chapter & section.
- Policy History section: Added.
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RPM050, “Risk Adjustment/HCC Coding and Documentation” |
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- Change to new header.
- Added Texas information for possible future Texas needs.
- Acronym table: 10 entries added.
- Policy History section: Added.
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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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- Change to new header.
- Acronym Table: 5 entries added.
- References & Resources: Added entries 9 – 17.
- Policy History section: Added.
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RPM072, “Supply Limits For Ongoing Medical Supplies” |
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- Change to new header.
- Coding Guidelines & Sources: 2 CMS quotes added.
- Cross References: 1 entry added.
- References & Resources: 2 CMS entries added.
- Policy History section: Added.
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Annual review/Formatting update: |
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RPM067, “RPM028, “Modifier 25 – Significant, Separately Identifiable E/M Service”of Care Review”
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- Change to new header.
- Policy History section: Added.
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RPM030, “Modifiers 54, 55, and 56 – Split Surgical Care” |
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- Change to new header. Changed Subsection from “None” to “Surgery.”
- Acronym table: 8 entries added.
- Definition of Terms: 1 entry added.
- Policy History section: Added.
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RPM031, “Modifier 47 - Anesthesia by Surgeon” |
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- Change to new header. Changed Subsection from “None” to “Surgery.”
- Acronym table: 7 entries added.
- Policy History section: Added.
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RPM033, “Qualifying Circumstances for Anesthesia” |
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- Change to new header.
- Acronym table: 5 entries added.
- Policy History section: Added.
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RPM036, “Modifiers GA, GX, GY and GZ” |
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- Change to new header.
- Acronym table: 7 entries added.
- Policy History section: Added.
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RPM038, “Computer Assisted Navigation” |
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- Change to new header.
- Acronym table: 9 entries added.
- Definition of Terms table: Added.
- Policy History section: Added.
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RPM042, “Revenue Codes Ending in "9" ("Other" Categories)” |
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- Change to new header. Changed section from “Administrative” to “Facility-Specific.”
- Acronym table: 10 entries added.
- Policy History section: Added.
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RPM056, “Medically Unlikely Edits (MUEs)” |
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- Change to new header.
- Acronym table: 2 entries added.
- MAI Definition table added.
- Policy History section: Added.
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RPM070, “Modifier SU - Procedure Performed in Physician’s Office (Facility and Equipment)” |
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- Change to new header.
- Acronym table: 6 entries added.
- Policy History section: Added.
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Medical Necessity Criteria updates
Medical criteria changes May and June 2022.
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May
Medical Criteria Summary
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Monochromatic infrared energy therapy |
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Introduction: This is an annual review.
Criteria changes:
Title updated to align policy requirements. Description updated. Policy addresses coverage for devices that may be utilized to provide infrared energy therapy. Minor grammar updates.
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Continuous glucose monitoring |
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Introduction: This is an annual review.
Criteria changes: Extended coverage for long-term continuous glucose monitoring for adolescents and children with type II diabetes
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Corneal collagen-treatment of Keratoconus |
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Introduction: This is an annual review
Criteria changes: No changes
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Intervertebral disc prosthesis |
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Introduction: This is an annual review
Criteria changes: No changes
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Bevacimumab (Avastin, Mvasi, Zirabev) (Intravitreal)
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Introduction: This is an annual review.
Criteria Changes: Bevacizumab biosimilars added into policy
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Introduction: This is an annual review
Criteria changes: No changes
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Introduction: This is an annual review
Criteria changes: Grammar update
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Introduction: This is an annual review
Criteria changes: Grammar update
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Temporomandibular Joint (TMJ) non-surgical treatment |
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Introduction: This is an annual review
Criteria changes: No changes
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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.
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Introduction: This is an annual review
Criteria changes: Minor grammar updates
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June
Medical Criteria Summary
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Introduction: This is an annual review
Criteria changes: No changes
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Introduction: This is an annual review
Criteria changes: Updated guidelines for breast implant removal.
Added, removal of cosmetically placed ruptured saline implants is
considered not medically necessary.
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Endoscopic procedures for treatment of Gastroesophageal Reflux Disease (GERD) |
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Introduction: This is an annual review
Criteria changes: No changes
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Introduction: This is an annual review
Criteria changes: No changes
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Medical nutrition therapy - Nutritional counseling |
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Introduction: This is an annual review
Criteria changes: No changes
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Mobile Outpatient Cardiac Telemetry (MOCT) |
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Introduction: This is an annual review
Criteria changes: No changes
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Negative pressure wound therapy (Vacuum-assisted wound closure) |
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Introduction: This is an annual review
Criteria changes: No changes
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Obstructive sleep apnea non-Surgical treatment |
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Introduction: This is an annual review
Criteria changes: No changes
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Panniculectomy
(Abdominal skin/fat surgery)
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Introduction: This is an annual review
Criteria changes: No changes
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Serum antibodies for diagnosis of inflammatory bowel disease |
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Introduction: This is an annual review
Criteria changes: No changes
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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
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Provider Updates
Credentialing Department
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Copyright © 2022. All Rights Reserved.
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