In this issue
- MP 2022 Year End Reporting
- Colorectal cancer screening
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Medicare year-end quality measures
summary reports due March 17
If your clinic participated in the 2022 Medicare Advantage Primary Care Incentive Program (MAPCIP), Moda Health and Summit Health are allowing you to submit a clinical summary report of measure results, instead of patient-level data, for the following quality measures:
- Controlling High Blood Pressure (CBP)
- Comprehensive Diabetes Care – HbA1c (CDC-HbA1c Poor Control)
- Colorectal Cancer Screening (COL)
Moda Health-specific, Summit Health-specific, or all-payer data is acceptable. The data must be submitted via an Excel template. Specific instructions are included in the template, and you must attest that the data is accurate.
To be eligible for the 2022 Performance Based Incentive Payment, your clinic’s quality measure performance summary report must be submitted to providerreports@modahealth.com by March 17, 2023.
Questions?
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New CGMA tool makes it easy to capture HCCs and close care gaps
- View and close care gaps
- Capture Hierarchical Condition Codes (HCCs) throughout the year
- Manage your patient roster
- View your incentive program progress.
Our goal with CGMA is to help you easily capture HCCs and close care gaps. The onboarding process does not require any lift on your part. You simply have to set up login access and the tool is ready to use.
Questions?
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Rewards for meeting quality gap closures and wellness visits in 2023
Our Moda Health and Summit Health value-based contracts, also known as the Medicare Advantage Primary Care Incentive Program (MAPCIP), rewards performance for meeting set thresholds for quality measure gap closures and certain wellness visits. Providers can earn:
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Care Gap Incentive Payment (CGIP): Per member per month (PMPM) payment based on annual performance on quality measures, patient experience of care measures and/or utilization measures
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Access to Care Incentive Payment (ACIP): PMPM payment based on members having completed an annual physical and/or annual wellness visit
For 2023, we will not require signatures on the updated MAPCIP amendment. Providers will be considered participants in our MAPCIP by meeting all three of the following requirements:
- Be certified by the Oregon Health Authority as a PCPCH Tier 1-5
- Perform one of the three require data submission activities including connection with Summit Health Provider Data Exchange (PDE), connection with Arcadia Analytics (available to Summit provider only), or utilization of Care Gap Management Application (CGMA) by Novillus
- Have a Medicare Advantage contract through Moda Health that is active and in good standing at the time incentives are disbursed in June 2024
Questions?
For questions about provider contracting and the 2023 Moda Health and Summit Health MAPCIP,
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Important update on GLP-1 diagnosis restriction
In November 2022, a new diagnosis restriction was placed on GLP-1 receptor agonist products indicated for type 2 diabetes mellitus (Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza) for Moda Health Commercial and Exchange members using therapy for the first time. The restriction limits these products to be used after their FDA-approved indication only. It should be noted that exclusions under a member’s plan benefit design, such as treatment for weight loss, still apply.
Starting on Feb. 1, 2023, this diagnosis restriction will also impact members who were previously on the therapy. These members were notified about this change in December.
Along with this diagnosis restriction, other applicable edits on GLP-1s will still be active. Select medications may first require step therapy or utilization of formulary alternatives.
What you’ll need to do
To help ensure claims can process quickly and accurately, please include the diagnosis (ICD-10 code) for the medication being used on all prescriptions for GLP-1s. The pharmacy needs to submit the diagnosis code in order to process claims. Any diagnosis besides the current FDA-approved indications will not be covered.
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Authorization requests for benign lesion removals
Attention dermatology providers! For a quick procedure that often takes place in the office, you may not realize that CPT 17110 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement] of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) requires an authorization.
If you need to remove a benign lesion and don’t have time to request a prior authorization, not to worry. We will accept a retroactive authorization as long as it is submitted within 14 days of the date of service.
Please note that we absolutely need to receive the retroactive authorization request within the 14-day date span. Any authorization request or appeal received after that will not be accepted, and the denial will not be overturned. Of course, if you know a lesion removal procedure will take place and can request an authorization ahead of time, that’s always better and easier for everyone involved.
Questions?
Learn more about this prior authorization requirement at
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HEDIS chart retrieval starts in February
From early February to early May, Moda Health and our chart retrieval partners will begin reaching out to providers to collect charts for the upcoming HEDIS season.
We use both Cotiviti and KDJ, so you may get requests from either vendor. These are valid requests. We ask that you provide the medical charts requested from these vendors. They are essential to the yearly HEDIS project and are protected through HIPAA as an operational function between the health plan and the provider.
You can provided these charts through EHR remote access, onsite retrieval or by fax/mail. For ease and efficiency, we encourage the use of remote access through EHRs.
Thank you for your time and effort this HEDIS season!
Questions?
If you have any questions or would like to set up remote access, please email us at HEDIS@modahealth.com.
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CDC: Colorectal cancer screenings should start at age 45
Colorectal cancer cases are on the rise among young and middle-aged people, with deaths of people under the age of 55 increasing 1% per year from 2008-2017. Because of these growing numbers, in 2021 the American Cancer Society recommended colorectal cancer screenings begin at age 45 rather than the previous ages of 50-75.
Colorectal cancer is most treatable when found early. However, the percentage of our members aged 45-49 receiving screening tests is still much lower than our members aged 50-75.
Moda Health encourages providers to offer these tests to all our members to screen for this disease. Please keep in mind that ages 45-49 are now included in the CDC’s recommendations for screenings.
NCQA recognizes the following tests to close colorectal cancer screening gaps:
- FOBT/FIT: Once every year
- FIT DNA (Cologuard): Once every 2 years
- Flexible Sigmoidoscopy: Once every 5 years
- CT Colonography: Once every 5 years
- Colonoscopy: Once every 10 years
Thank you for all that you do to keep our members safe and healthy!
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Reimbursement Policy Updates
The following table includes RPM updates for December 2022 to January 2023.
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Reviewed in December 2022 |
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RPM015, “Drugs and Biologicals, Wastage and/or Discarded Amounts (Modifier JW)” |
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- Change to new header; includes Idaho.
- Section C.2.c: Wastage documentation requirements revised to better address Pharmacy wastage at time of infusion preparation versus discontinuation of infusion at time of administration. (This change is subject to 28 TAC.)
- Coding Guidelines: Added (CMS1) quote update.
- Acronym table & Background Information: Updated.
- Policy History section: Added.
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Clarification, no policy changes: |
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RPM011, “Global Surgery Package for Professional Providers” |
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- Section F.3.c: Clarification of global surgery follow-up visit bundling & documentation requirements.
- Cross References: Hyperlinks added.
- References & Resources and footnotes: Updated.
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RPM052, “Telehealth And Telemedicine Services” |
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- Change to new header; Idaho is included but not checked. Section field changed from “Medicine” to newly created “Telemedicine.”
- Section A.5.b - Clarification of long-standing same specialty policy for non-physician practitioners added per provider inquiry. 2 related References & Resources added.
- Section B.4, C.3, & D.4: Clarification of using modifier 25 when face-to-face E/M leads to originating site Q3014 for same-day telehealth consultation for specialty/higher level of care visit.
- Section F.2: Preventive E/M codes added for Medicaid.
- Acronym Table: Updated.
- Cross References: Hyperlinks added.
- Policy History section: Added.
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RPM065, “Facility Guidelines, General Overview” |
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- Section D.5: Clarification of correct codes for hospitals to use for billing observation services with 2 related footnote sources added.
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RPM067, “Level of Care Review” |
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- Section E: Clarification of correct codes for hospitals to use for billing observation services with 2 related footnote sources added.
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RPM073, “Telehealth and Telemedicine Expanded Services for COVID-19” |
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- Change to new header; Idaho is included but not checked. Section field changed from “Medicine” to newly created “Telemedicine.”
- Cross References: Hyperlinks added.
- Policy History section: Added.
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RPM076, “2021 & 2023 Updates to Evaluation and Management (E/M) Visits and Prolonged Services” |
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- Header/Scope: Idaho added to States field.
- Title change & major revision to incorporate 2023 E/M changes.
- Added Determining Specialty for Non-Physician Practitioners (NPP) per provider inquiry on RPM041.
- Acronym table & Definition of terms: new additions.
- References & Resources: 21 entries added.
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RPM001, “Moda Health Reimbursement Policy Overview” |
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- Header/Scope: Idaho added.
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RPM004, “After Hours and Other Special Circumstances” |
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- Header/Scope: Idaho added.
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RPM007, “Modifier 22 – Increased Procedural Services” |
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- Header/Scope: Idaho added.
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RPM013, “Modifiers 80, 81, 82, and AS – Assistant at Surgery” |
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- Header/Scope: Idaho 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. Includes Idaho.
- Converted to outline format.
- Modifier table added.
- 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. Includes Idaho.
- Acronym table: 7 entries added.
- Cross References: 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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- Policy name: “Professional Claims” changed to “Professional Providers.”
- Change to new header. Includes Idaho.
- Moved from Administrative to Surgery section.
- Cross References: 1 entry 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; includes Idaho.
- Acronym table: 1 entry added.
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RPM066, “DRG Payment With Patient Transfers” |
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- Change to new header. Includes Idaho.
- Policy History section: Added.
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- Change to new header. Includes Idaho.
- Cross References: 2 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. Includes Idaho.
- Converted to outline format.
- Policy History section: Added.
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RPM075, “Emergency Department Visit Leveling” |
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- Change to new header. Includes Idaho.
- Policy History section: Added.
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Clarification, no policy changes: |
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RPM053, “Diagnosis Code Requirements - Level of Detail, Number of Characters, and Laterality” |
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- Section B.2: “primary or secondary” changed to “in any position” for clarity.
- Cross References: Hyperlinks added.
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RPM059, “Radiology Reductions for Technology Type - Modifiers FX and FY” |
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- Updated payment discount amounts based on claim type and date of service to be consistent with CMS policy documentation. Footnotes included.
- References & Resources: 2 entries added.
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Medical Necessity Criteria updates
The following table includes medical criteria updates for November 2022 to January 2023.
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November 2022
Medical Criteria Summary
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Cardiac defibrillators, external |
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Introduction: This is an annual review
Criteria changes: No changes
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Cryoablation of breast adenomas |
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Introduction: This is annual review.
Criteria changes: Policy to be archived
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Hearing assistive technology |
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Introduction: This is an annual review
Criteria changes: No changes
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January 2023
Medical Criteria Summary
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Balloon dilation of eustachian tube |
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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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Cochlear implants and auditory brainstem implants |
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Introduction: This is an annual review
Criteria changes: No changes
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Durable Medical Equipment (DME)
general policy
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Introduction: This is an annual review
Criteria changes: Updated NCD-CMS link
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Experimental and investigational services |
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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 update
Criteria changes: added ‘F50.82 Avoidant/restrictive Eating Disorder’
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Introduction: This is an annual review
Criteria changes: Created a Moda Health medical necessity criterion to mirror the Pharmacy Rx policy. This eliminates discrepancies that may lead to confusion when a Pharmacy Rx policy or Moda Health medical necessity criteria is utilized for review.
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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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