Oregon |January/February 2019
Coverage changes for specialty injectables

Moda Health and Ardon Health are expanding the current program for managing specialty medications to include infused medications. These changes only apply to all Oregon Moda Health commercial fully insured members, including group and individual members. They are designed to provide consistent, quality service and an enhanced member experience with lower out-of-pocket costs for our members.

Effective April 1, 2019, the following select infused specialty medications will only be covered under the pharmacy benefit. Any claims submitted under the medical benefit will be denied. Claims for the administration of the medication should continue to be billed to the member’s medical benefit.
These prescriptions should be sent to Ardon Health or participating pharmacies for processing and fulfilment rather than being obtained through the “buy and bill” process. Please note that Ardon Health does not have access to Spinraza. At this time, it should only be sourced from a participating pharmacy.

Prior authorization requests for these infused specialty medications should be submitted through the CoverMyMeds ePA tool at covermymeds.com . Members may also contact Ardon Health or participating pharmacies directly.

This benefit change does n ot currently apply to Moda Medicare Advantage, ASO or OHP/EOCCO members.

Visit our infused specialty medications page for a full list medications covered only under the pharmacy benefit, and for groups where these medications are covered under the medical benefit. New medications may be added to the list at the time of FDA approval.

To learn more about infused specialty medication benefits, email medical@modahealth.com or call us at 877-605-3229.
Reimbursement changes for sinus endoscopies and debridements

We want to make you aware of some important changes that affect how we reimburse for sinus endoscopies and debridements performed during the global period of a previous nasal or sinus surgery.

Effective for dates of service April 1, 2019 and after , CPT 31231, 31237 and S2342 will no longer be eligible for separate reimbursement unless the procedure requires the patient to return to an operating room outside of the office setting. This change applies to all Moda Health Commercial, Medicare Advantage and OHP/EOCCO members’ postoperative sinus endoscopy and/or debridement procedures.
Modifier 58 can no longer be appended to procedure codes 31231, 31237 and S2342 to receive separate payment during the 10-day or 90-day global period following another nasal or sinus surgical procedure (e.g., 30520). Moda Health will deny 31231-58, 31237-58 or S2342-58 as an invalid procedure code, as well as any facility or provider write-off charges.

Moda Health considers 31231, 31237 and S2342 to be routine follow-up wound care for nasal surgeries. This is similar to an orthopedic or abdominal surgeon doing in-office wound checks, irrigations, debridement and dressing changes, which should not be separately billed to the global surgery fee.
When all of the procedure codes performed at the original surgical session have zero follow-up global days, then postoperative sinus endoscopies and/or debridements should be reported without appending modifiers 58, 78 or 79.

Check out Moda’s Postoperative Sinus Endoscopy and/or Debridement Procedures Reimbursement Policy here . Or see a full list of our reimbursement policies .
New preferred medications for long-acting G-CSF injections

As part of our commitment to provide members with high quality, affordable care, Moda Health has selected Neulasta® (pegfilgrastim) and Udenyca TM (pegfilgrastim-cbqv) as the preferred long-acting granulocyte colony-stimulating factor (G-CSF) products.

Effective April 1, 2019 , Magellan Rx will review prior authorization requests for all fully insured groups and individual members, and select ASO groups for G-CSF injections that include the products listed below. Moda will review G-CSF injections provided to all other members.
Members who receive G-CSF injections will be limited to the preferred products unless the non-preferred product is deemed medically necessary. Members currently receiving G-CSF injections with a non-preferred product may complete their current course of therapy as it applies to the existing authorization period.

If there is clinical documentation that Neulasta or Udenyca are ineffective, not tolerated or disproven to be effective, Fulphila TM (pegfilgrastim-jmbd) may be administered with a prior authorization approval by Magellan Rx.

Completing prior authorization requests through Magellan Rx will help speed up claims processing and does not require you to submit medical records. If you do not obtain a prior authorization, your claims may be delayed or denied until we receive the information needed to establish medical necessity. 
Request a PA today!
Follow these easy steps to request prior authorizations through Magellan Rx:
1.      Visit the Magellan Rx website .
2.      Select “New Access Request – Provider” on the right side of the page.

Learn more about our G-CSF medical necessity requirements on our medical necessity criteria page .
New online platform for ePA requests

Moda Health has partnered with CoverMyMeds to process electronic prior authorization (ePA) requests for medications covered under a member’s pharmacy benefit.

CoverMyMeds is a free online platform that accepts requests from your office’s electronic health record system, or directly through the CoverMyMeds portal. Prescribers and staff can start using CoverMyMeds to submit ePA requests that utilize Moda’s custom criteria and question sets for all Moda Commercial, EOCCO and Medicare Advantage members.

Please note that you must select the form specific to the line of business when submitting an ePA for your patient.

CoverMyMeds’ PA process helps you make faster determinations and an automatic PA renewal setup that supports medication adherence with your patients.

New to CoverMyMeds?
Visit the CoverMyMeds website to create a free account. Weekly webinar trainings are available. CoverMyMeds is happy to schedule personalized webinars at a day and time that’s convenient for you. Just email help@covermymeds.com or chat live to request a demo.
EDI programming error fixed

Moda Health recently identified an Electronic Data Interchange (EDI) programming error that incorrectly reported provider write-off charges as patient liability charges on Electronic Remittance Advice (ERA) files from November 2018 to January 2019.

Moda Health corrected the error and current ERA files now report correct provider write-off and patient liability charges. Provider Disbursement Registers (PDRs) remitted to your practice via mail were not impacted, and correctly report provider write-off and patient liability charges.

To ensure that all accounts have been correctly posted and all members have received accurate bills, please review claim information in Benefit Tracker

If you have any questions, please email medical@modahealth.com or call the Moda Health Medical Customer Service team at 877-605-3229.
Injectable medication expansion

Starting March 1, 2019 , Bortezomib will be added to the prior authorization list of medications that are currently in the Magellan Rx program. Magellan Rx will review all 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
Learn more about the injectable medication program and view the current medication list .
Post Service Claim Edit expansion

Magellan Rx has partnered with Moda Health to expand its claim check program to promote appropriate use, safety and cost effectiveness of medications prescribed to our members.

Effective April 1, 2019 , Moda will review claims for appropriate frequency, correct units and eligible diagnosis codes for the following medications:
Prior authorization criteria do not apply to these medications. Moda applies post-service, pre-payment claims edits to diagnosis criteria and criteria for maximum units for all medications included in the claims edit program.

Learn more about our claims edits policy here .
Electronic claim processing enhancements

Moda Health’s Electronic Data Interchange team has made enhancements to improve claims processing times. This upgrade should have minimal impact on most provider offices. However, your practice may see an increase in rejected claims due to one or more of the following errors:

  • PO Box is listed as the physical address
  • Invalid NPI
  • Invalid NDC
  • Claim submission date prior to the date of service

We’ve also worked to reduce duplicate denials by enhancing our system to identify claim frequency type codes.

If you receive a rejected claim, please contact your clearinghouse vendor to help resolve the issue. If you think a mistake was made, and your clearinghouse vendor cannot identify the issue, please email the Moda Health EDI team at edigroup@modahealth.com .
Medical necessity criteria updates

Effective March 1, 2019

Learn more on our   medical necessity criteria page.
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
For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests 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

Coverage changes for specialty injectables

Reimbursement changes for sinus endoscopies and debridements

New preferred medications for long-acting G-CSF injections

New online platform for ePA requests

EDI programming error fixed

Injectable medication expansion

Post Service Claim Edit expansion

Electronic claim processing enhancements

Medical necessity criteria 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 Findcare 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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