Oregon |January/February 2018
Servicing facility location claim documentation

Beginning March 1, 2018, a new Oregon state requirement will apply to any Moda member insured on an Oregon commercial group or individual plan. When services are performed by an out-of-network provider in an in-network facility, the member’s in-network cost-sharing will apply. In these situations, providers are prohibited from balance billing the member for amounts above the amount Moda pays for the out-of-network service rendered.

In response to this state mandate, we ask that you complete the Servicing Facility Location Information (box 32) of the CMS-1500 claim form, with the facility’s name, address and NPI so that we may more accurately monitor these scenarios. This is the same approach we took in response to the federal mandate that was effective Jan. 1, 2018.

If the Service Facility Location Information is not completed, the claim will be denied with EX code 7AF “service facility location is missing,” and a corrected claim will need to be submitted.

We appreciate your time and attention as we strive to ensure Moda members get the most out of their health benefits.

We’re here to help! If you have questions related to Servicing Facility Location Information claim form requirements listed above or Denial Code 7AF, please email medical@modahealth.com or call 877-605-3229.
Moda Health strengthens provider partnerships through onsite visits

In support of Moda Health’s commitment to ensuring our provider partners have the tools and resources needed to efficiently provide quality care to Moda members, the Moda Health Provider Relations team will be conducting onsite provider visits throughout 2018.

With a focus on fostering collaborative relationships, the Moda Health Provider Relations team will work side-by-side with your practice’s office staff to advise, educate and inform on several topics including:

  • Reviewing member benefits
  • Referral and authorization processes
  • Utilization management programs
  • Clinical guidelines
  • And more!

For more information or to schedule an onsite provider visit, please email your Provider Relations Representative, or click here to locate your region’s representative.
Authorization for ultrasound services no longer required

On April 1, 2017, Moda Health transitioned its utilization management programs for advanced imaging and musculoskeletal services to eviCore healthcare. Utilization management helps make sure that patients get the highest quality care. With the transition to eviCore, we have been able to offer utilization management for more services. One such example is the ultrasound program, which includes both OB-GYN and non-OB-GYN ultrasounds.

As an organization focused on innovation and partnership, Moda continuously evaluates the performance of its programs. After careful consideration of the ultrasound program experience as well as the provider and member impact Moda has elected to discontinue prior authorization requirements for ultrasounds. Effective Jan. 1, 2018, and applicable to all commercially insured and EOCCO plans, prior authorizations for ultrasounds, either OB-GYN or Non-OB-GYN, are no longer required.

Click here to learn more about Moda’s utilization management programs. You may also call our Customer Service team at 877-605-3229.
The 2018 HEDIS season starts soon!

Moda Health’s annual data collection for our 2018 Healthcare Effectiveness Data and Information Set (HEDIS) will start in early February and continue through early May. The Moda Health members for this project were identified through a randomized selection process using claims data. These activities are defined as healthcare operations under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, and thus, patient authorization is not required.

This year, we are again partnering with CIOX Health, a record retrieval organization. We are collecting data on the following measures:

  • Adult BMI
  • Cervical
  • Colorectal cancer screenings
  • Childhood and adolescent immunizations
  • Diabetes care
  • Controlling high blood pressure
  • Prenatal and postpartum care
  • Weight assessment and counseling for children and adolescents
  • Medication reconciliation
  • Transition of care

There are several ways in which your medical records can be collected. You can schedule an onsite appointment to retrieve your records, or you can fax, mail, or upload them to secure FTP. Additionally, if you have an EMR system, we can establish remote access. We greatly appreciate your cooperation for the retrieval of medical records. 

If you have any questions or concerns about this request, please email the Moda Health HEDIS team at hedis@modahealth.com. You can also reach the CIOX Health Provider Support Center at 877-445-9293.

Thank you for partnering with Moda Health to pursue the highest quality among America’s health plans.
CDC recommendations for pneumococcal vaccinations

In the United States about 900,000 patients get pneumococcal pneumonia each year, and 95 percent of pneumococcal deaths that occur are within the adult population. Yet adult vaccination rates are low. Eighty percent of adults remain unvaccinated while having conditions that place them at increased risk. 1

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends a pneumonia vaccination series to adults ages 65 and older. Additionally, certain patient populations ages 19 to 64 are at increased risk for pneumococcal disease and are recommended to receive a pneumococcal vaccine, specifically, the pneumococcal 23-valent polysaccharide (PPSV23) vaccine.

The CDC recommends that patients ages 19 to 64 should receive PPSV23 if they have the following conditions: chronic heart disease including congestive heart failure and cardiomyopathies (excluding hypertension); chronic obstructive pulmonary disease (COPD), emphysema and asthma; chronic liver disease; alcoholism; or diabetes mellitus; or who smoke cigarettes. 2

It is important to review your patient’s immunization history and consider administering a pneumococcal immunization if deemed appropriate. As a reminder, any Individual, small or large group, Medicare Advantage, or EOCCO/OHP member may be immunized at their local in-network pharmacy for a $0 copay.

1.        Centers for Disease Control and Prevention. Pneumococcal Disease: Surveillance and Reporting. https://www.cdc.gov/pneumococcal/surveillance.html . Accessed Feb. 2, 2018.
2.        Centers for Disease Control and Prevention (2017). Advisory Committee on Immunization Practices recommended immunization schedule for adults age 19 and older-United States, 2017. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf . Accessed Feb. 2, 2018.
New Medicare ID cards coming soon

The Centers of Medicare and Medicaid Services (CMS) will begin issuing new identification cards to all Medicare beneficiaries, beginning April 2018.

The new cards will use a Medicare Beneficiary Identifier (MBI), which is a random assignment made up of alpha and numeric characters, and has no base in the member’s social security number. The complete transition to the new cards is expected to be finished by January 2020.

CMS’ MBI card project makes no change in the way you will bill Moda Health for Medicare Advantage members. Please continue to use the Moda assigned group and identification number for these Medicare Advantage members. However, you will need to use the new MBI when billing claims for your patients who are on Original Medicare.

You can find out more about the new Medicare Beneficiary Identifier here .
Cost-sharing for Qualified Medicare Beneficiaries (QMB)
The Qualified Medicare Beneficiary program assists low-income Medicare beneficiaries with premiums and cost-sharing, including deductibles, coinsurance, and copayments. The Centers for Medicare and Medicaid Services (CMS) latest article dated Dec. 4, 2017, (SE1128) reminds all Medicare physicians, providers and suppliers serving beneficiaries enrolled in either Original Medicare or a Medicare Advantage plan that a QMB has no legal liability to pay Medicare providers for Medicare cost-sharing.

Providers and suppliers may bill state Medicaid programs, however states can limit Medicare cost-sharing payments under certain circumstances.

Ways to identify a QMB enrollee include:

  • Refer to State online Medicaid eligibility systems/documentation, including Medicaid ID cards
  • Review the Medicare Provider Remittance Advice about a patient’s QMB status
  • Contact Moda Health’s Medicare Advantage Customer Service at 877-299-9062

How to maintain compliance:

  • Establish processes to routinely identify the QMB status of your patients prior to billing
  • Determine the billing processes that apply to seeking payment for Medicare cost-sharing from the states in which you operate
  • Ensure that billing procedures and third-party vendors exempt QMBs from Medicare charges and remedy billing problems should they occur

You can find out more about the Qualified Medicare Beneficiary program here .
Medical necessity updates

We've recently updated our medical necessity criteria. You can find the following changes 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

Servicing facility location claim documentation 

Moda Health strengthens provider partnerships through onsite visits 

Authorization for ultrasound services no longer required

The 2018 HEDIS season starts soon!

CDC recommendations for pneumococcal vaccinations

New Medicare ID cards coming soon

Cost-sharing for Qualified Medicare Beneficiaries (QMB) 

Medical Necessity updates
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If you want to start exchanging information electronically with Moda, please contact the Moda Electronic Data Interchange team at edigroup@modahealth.com
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Help us keep your practice details updated

To make sure we provide high-quality service to our members, Moda's "Find a Provider" online search tool helps members connect with our extensive network of contracted providers. To meet the CMS requirement of having updated information about your practice or facility for our members, please email our provider updates team at
providerupdates@modahealth.com when any of the following changes occur, including the effective date:

  • New street address, phone number or office hours
  • Changes in the "When you are accepting new patients" status for all contracted Moda lines of business
  • Changes that affect the availability of providers in your practice

This will help make sure our members can find providers that are available and best suit their needs.

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