Oregon | January/February 2017 

Prior authorizations with eviCore healthcare

As part of Moda Health’s efforts to provide our plan holders with access to high-quality, cost-effective care, on April 1, 2017, Moda will be replacing AIM Specialty Health with utilization management programs for advanced imaging services (cardiology, radiology, ultrasound) with eviCore healthcare. This partnership also includes musculoskeletal services (spine/joint surgery, spine/joint pain management, physical therapy/occupational therapy/speech therapy and alternative care) with eviCore. 

Advanced imaging and musculoskeletal prior authorization requirements for Moda members will vary depending on the line of business and employer group enrollment in eviCore’s utilization management program. eviCore will begin accepting prior authorization requests on March 27, 2017.

To see if your patient is employed by a group that requires prior authorization through eviCore for advanced imaging or musculoskeletal services, please log in to Moda’s Benefit Tracker for specific member benefits.

Services performed without prior authorization will be denied to provider write-off and members may not be billed for these services.

To obtain a prior authorization request through eviCore for advanced imaging or musculoskeletal services, you may register with eviCore by visiting www.evicore.com.

eviCore healthcare is continuing to lead orientation sessions designed to assist you and your staff with the programs. Additionally, for detailed questions specific to your practice, please reach out to your Moda Medical Provider representative and request onsite training with eviCore.

For more information on Moda’s advanced imaging and musculoskeletal utilization management programs, please visit ww.modahealth.com/medical/utilizationmanagement.shtml.

HEDIS 2017 medical record review

It is HEDIS season again and Moda Health is required to collect HEDIS information annually from our participating providers. Each year we review a sample of charts to evaluate quality measures.  This year we are working on 10 quality measures.   We will be partnering with CIOX Health (formally known as ECS) and KDJ Consultants to collect and review charts.  CIOX Health and/or KDJ Consultants will be contacting you starting in February if any of your members have been selected for chart review. 

Data exchanged between providers, health plans, and contracted health plan vendors, is covered under the HIPAA Privacy Rule for HEDIS as part of the “health care operations” or quality improvement activities.

HEDIS 2017 measures

  • Adult BMI Assessment 
  • Comprehensive Diabetes Care
  • ervical Cancer Screening
  • Controlling High Blood Pressure
  • Childhood Immunizations
  • Prenatal and Postpartum Care
  • Adolescent Immunizations
  • Weight Assessment and Counseling for Children
  • Colorectal Cancer Screening
  • Medication Reconciliation Post Discharge
The following are some tips to help facilitate the HEDIS data collection process:
  • Anticipate CIOX’s call and plan for preferred method of retrieval.
  • If your office is contacted, please respond within five business days to help ensure a timely response.
  • If you do not have a chart that is being requested, please indicate by marking the pull list C.N.A and this will avoid further calls from CIOX.
  • If you would like to arrange remote access to reduce or eliminate HEDIS chart requests in the future, please contact the HEDIS team at hedis@modahealth.com
Our goal is to make this as simple and smooth a process as possible. If you have any questions or concerns about this request, please contact CIOX Health Provider Support Center at 1-877-445-9293.  You can reach the Moda HEDIS team at hedis@modahealth.com . You can also contact Diana Dass, Medical Record Coordinator for urgent issues via phone at 503-412-4168. Thank you for partnering with Moda to pursue the highest quality among America’s health plans.

For more information on the 2017 HEDIS medical record review, please see our  FAQ .

HEDIS Measure: Controlling Blood Pressure

Approximately 1 of 3 U.S adults (75 million people) have high blood pressure. Of these, it is estimated that only  54% of these people have their high blood pressure under control. 1 Controlling blood pressure is an important step in preventing heart diseases, which is why it is recommended to check your blood pressure regularly. Below are a few helpful tips to assist with proper documentation and to promote patient adherence for controlling high blood pressure.

Measure Definition: The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:

  • Members 18–59 years of age whose BP was <140/90 mm Hg.
  • Members 60–85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
  • Members 60–85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. 2
  Provider tips when talking to the patients:
  • It is important to remind patients with hypertension about taking prescribed medications, encouraging low-sodium diets, and increased physical activity.
  • Encourage patients to check their blood pressure regularly.
  • Include more than one blood pressure per visit: If the patient has a high blood pressure reading at the beginning of the visit, retake and record it at the end of the visit.
  • You can improve medication adherence and reduce member costs by promoting 90 days fills or mail order prescriptions.
  • Ensure that proper documentation is included in the medical record.
  • Provide patients with education resources from the Center for Disease Control and Prevention.3

1 Merai R, Siegel C, Rakotz M, Basch P, Wright J, Wong B; DHSc., Thorpe P. CDC Grand Rounds: A Public Health Approach to Detect and Control Hypertension
2 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS 2017 Technical Specifications for Health Plans (National Committee for Quality Assurance 2017), 116-121
Control Hypertension. MMWR Morb Mortal Wkly Rep. 2016 Nov 18;65(45):1261-1264

HEDIS Measure: Colorectal Cancer Screening (COL)

Many colorectal cancers can be prevented through regular screenings. Colorectal screening is crucial because it may also lower mortality by allowing detection of cancer at earlier stages, when treatment is more effective1.  Below are a few helpful tips to promote colorectal cancer screenings for your patients.

Measure definition: The percentage of members 50-75 years of age who had appropriate screening for colorectal cancer 2.

Any of the following meet the criteria:
  • Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned, regardless of FOBT type.
  • Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.
  • Colonoscopy during the measurement year or the nine years prior to the measurement year.
Provider tips when talking to the patients:
  • Understand the power of physician recommendation and discuss the importance of colorectal cancer screening to patients ages 50 and older.
  • It is also important to obtain any family history of a parent, sibling, or child with colorectal cancer, especially if the family member was diagnosed prior to age 60.
  • Rely on your staff to alert patients who are due for screening, even if they are not coming in for a wellness visit.
  • Be sure to discuss alternatives to colonoscopy screening if your patient cannot or will not have a colonoscopy.
2HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS 2017 Technical Specifications for Health Plans (National Committee for Quality Assurance 2017), 80-82

Injectable medication program expansion 

Effective April 1, 2017 , four new medications will be added to the  prior authorization list of medications currently in the Magellan Rx program. Magellan Rx will review your prior authorization requests for these specialty injectable medications, along with other specialty medications that are already part of the program when administered in:
  • An outpatient facility
  • A patient's home
  • A physician's office

For more information on Moda’s Injectable Medication program, visit modahealth.com/medical/injectables/.

Claim edit expansion

MagellanRX has partnered with Moda to expand its claim check program to promote appropriate use, safety, and cost effectiveness of medications prescribed to our members. Beginning April 1, 2017, Moda will be reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes for the following medications:

To learn more about our claims edits policy, please visit www.modahealh.com/medical/claim_edits_policy .

Tablet splitting guidance

Tablets are one of the most highly utilized dosage forms of oral medications and many tablets are manufactured with scoring to facilitate tablet splitting. While tablet splitting is usually not necessary for common doses of the majority of medications, it may be a useful practice when less than a full tablet is desired. Below are recommendations for when tablet splitting may or may not be appropriate:

  • Ideal medications for tablet splitting: Immediate-release tablets 
  • Medications that should not be split: Capsules, extended-release, or delayed-release dosage forms
  • A good resource to identify medications that should not be split is the Institute for Safe Medication Practices (ISMP) “Do Not Crush” List available at: www.ismp.org/tools/
  • Counseling points for patients: 
  • Use a pill splitter.
  • Do not split in advance and store for later use as heat and humidity may affect the split tablet.
  • A potential for cost savings is associated with splitting flat-priced tablets (e.g., when the cost of a 20 mg tablet is similar to that of a 10 mg tablet).
  • Examples of flat-priced immediate-release tablets: amlodipine, carvedilol, citalopram, glimepiride, glipizide, lisinopril, losartan, rosuvastatin, sertraline, simvastatin.
  • Keep in mind: One risk of tablet splitting is a potential for variance in dose. Risks and benefits should be weighed prior to recommending tablet splitting.

Medication availability informational updates

The table below provides a medication pipeline update regarding medications that have been recently approved or medications that are now available in generic formulation:

Medical necessity updates

We've recently made a number of updates to our medical necessity criteria. You can find the following changes online at our medical necessity criteria website.

Moda Contact Information

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 Services
To reach our Provider Services department, please email providerrelations@modahealth.com .

Medical Professional Configuration
For provider demographic and address updates, please email providerupdates@modahealth.com .

Credentialing Department
For credentialing questions and requests, please email credentialing@modahealth.com.

In this Issue

Prior authorizations with eviCore healthcare

HEDIS 2017 medical record review

HEDIS Measure: Controlling Blood Pressure

HEDIS Measure: Colorectal Cancer screening (COL) 

Injectable medication program expansion

Claim edit expansion

Tablet splitting guidance

Medication availability informational updates

Medical necessity updates
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