In this issue
  • New groups adding Magellan Rx services

  • Join our Summit Health Medicare Training

  • Introducing a new Medicare Advantage plan for Eastern Oregon

  • Medical policy updates
Join our email list
Join our email list in order to begin receiving bi-monthly newsletters, as well as occasional electronic communications. 
New groups adding Magellan Rx services

Moda Health’s partnership with Magellan Rx Management is expanding. Starting Jan. 1, 2021, Magellan Rx services will include Multnomah County (Group #: 10001684) and OHSU Employees (Group #: 10001819).

This partnership has three components to help us provide members with high quality, affordable care. They include the Injectable Drug Program, Site of Care (SOC) and Post Service Claims Edits (PSCE). 

  • Prior authorization for provider-administered infusions and injections: To learn more and find out which medications require prior authorization through Magellan Rx, please visit modahealth.com/medical/injectables. You can request prior authorizations through the Magellan Rx self-service portal at ih.magellanrx.com. Then, select “New Access Request-Provider” on the right side of the home page.


 
Introducing a new Medicare Advantage plan for Eastern Oregon

As a valued provider partner, we thank you for being part of our network. We also want to make sure you have the most current information about some changes to our Medicare Advantage membership, and what these changes mean to you.
 
In 2021, Moda Health will no longer be offering Medicare Advantage plans in Eastern Oregon. We will, however, continue to offer Moda Health Medicare Advantage plans in Western Oregon and Medicare Supplement plans statewide. Moda Health will also be the administrator of a new Medicare Advantage Insurance company in Eastern Oregon called Summit Health, Plan Inc. 
 
As part of Moda’s family of healthcare companies, Summit Health builds off the success of the Eastern Oregon Coordinated Care Organization (EOCCO). Like EOCCO, Summit Health’s business is founded on a partnership between Moda and a number of Eastern Oregon healthcare providers and health systems, including:

  • Eastern Oregon IPA
  • Greater Oregon Behavioral Health, Inc (GOBHI)
  • Good Shepherd Health Care System
  • Grande Ronde Hospital
  • Moda
  • Saint Alphonsus
  • St. Anthony Hospital
  • Yakima Valley Farm Workers Clinic
Join our Summit Health Medicare Training

Please join us for the first Summit Health Medicare Provider Training. This online training is designed for office managers, billing managers, referral and authorization managers, and other staff interested in learning more about the new Summit Health Medicare offerings in Eastern Oregon.

Sign up today!
Follow these easy steps to sign up for one of our upcoming provider trainings.
 
  1. Click on one of the following registration links to register for the training time that works best for you.
  2. Make sure to register each person attending from your clinics/office/hospital separately.
  3. You may also register online at yoursummithealth.com/provider/provider-training.


Questions?
We’re here to help. If you have questions, please contact Noah Pietz at providerrelations@yoursummithealth.com.
Thursday, December 10
9 – 10:30 a.m.


Thursday, December 10
12:30 – 2 p.m.


Tuesday, December 15
9 – 10:30 a.m.


Tuesday, December 15
12:30 – 2 p.m.


Wednesday, January 6
9 – 10:30 a.m.


Wednesday, January 6
12:30 – 2 p.m.
Questions?
We’re here to help. You can reach us by emailing Summit Health Provider Relations at providerrelations@yoursummithealth.com or Moda Health Provider Relations at providerrelations@modahealth.com.
 
We appreciate your partnership in helping these Medicare members get the quality care and services they deserve.
Medical policy updates

Criteria
August Medical Criteria Summary
Pharmacy/ Medical
AFO/KAFO/HKAFO
Introduction:
This is an annual review.

Criteria changes:
Minor grammar changes.
Medical
Air Ambulance
Introduction:
This is an annual review.

Criteria changes:
  • Minor format changes; an indication where air transport is considered E/I or not medically necessary as a stand alone requirement
  • Reworded coverage guidelines for member who is unable or inappropriate for air transport
Medical
Cochlear Implants and Auditory Brainstem Implants
Introduction:
This is an update.

Criteria changes:
The coverage for unilateral or bilateral cochlear implantation for children was updated to include children as young as 9 months. This follows a recommendation from the American Association of Otolaryngology and an FDA update that says if implantation is appropriate, then children should receive cochlear implants as soon as possible, since this has been correlated with better language outcome. 
Medical
Cranial Orthotics
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Factor V Leiden
Introduction:
This is an annual review.

Criteria changes:
Minor grammar updates. No content changes.
Medical
Knee Cartilage Transplants
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Medical Nutrition
Therapy/Nutritional Counseling
Introduction:
This is an update.

Criteria changes:
  • Added a section that includes guidelines to allow coverage for nutritional counseling for members that are considered underweight and present with a diagnosis of failure to thrive
  • Added a reference to the Nutritional Therapy for Eating Disorders policy for requests that are identified for treatment of eating disorders. Included a list of what is considered as eating disorders (National Eating Disorders Association {NEDA})
Medical
Mobile Outpatient Cardiac Telemetry
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Obstructive Sleep Apnea Non-Surgical Treatment
Introduction:
This is an annual review.

Criteria changes:
  • Added details to the requirements for Auto PAP, CPAP and BiPAP coverage to provide clear and concise descriptions
  • Updated grammar for coverage requirements for tongue retaining devices/mandibular advancement oral appliances
Medical
Push-Rim Activated Power Assist Device
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Upper Extremity Orthoses
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Criteria
September Medical Criteria Summary
Pharmacy/ Medical
Allergy Testing-Blood
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Anesthesia for Routine Gastrointestinal Endoscopic procedures
Introduction:
This is an annual review.

Criteria changes:
Added clarification; marijuana use, intermittently or frequently, does not by itself require MAC anesthesia
Medical
Breast Pumps
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Computer Assisted Navigation for Musculoskeletal Procedures
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Cooling Devices
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Electron Beam Computed Tomography (EBCT)
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Gender Confirming Surgery
Introduction:
This is an update.

Criteria changes:
Added Section G. Guidelines for Gender Confirming Facial Procedures. Added related Cpt codes. Updated procedures considered experimental and investigational.
Medical
Interferential Stimulation Devices
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Patient Lifts (electric or movable)
Introduction:
This is an update.

Criteria changes:
No content changes.
Medical
Reduction Mammoplasty
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Medical
Therapeutic Drug Monitoring
Introduction:
This is an update.

Criteria changes:
No content changes.
Medical
Criteria
September Behavioral Health Criteria Summary
Nutrition therapy for eating disorder
Introduction:
Cross-reference medical criteria set.

Criteria changes:
No other changes.
Adjustment disorder
Criteria changes:
Retire.
Chemical Dependency treatment
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Dissociative disorder
Criteria changes:
Retire.
Long-term psychotherapy
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Reactive attachment disorder
Introduction:
This is an annual review.

Criteria changes:
No content changes.
Contact us
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
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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