Oregon | July/August 2017 
2017 Provider workshops are just around the corner

Moda's 2017 Medical Provider Workshops are set to begin October 17, 2017. Join us to learn about our 2017 updates and get a glimpse of what's ahead for 2018.

Be sure to visit  our workshop  website to sign up for a workshop near you to get a seat today.
Authorization extensions in eviCore's utilization management program

Over the past few months, we’ve greatly appreciated your support and patience as we work with eviCore healthcare to incorporate your feedback and refine processes with our advanced imaging and musculoskeletal utilization management programs. We are pleased to communicate that we’ve recently increased the length of time allowed to submit ultrasound authorization requests and we have extended the waiver periods for eviCore’s Therapy and Alternative Care programs.

Increased authorization submission timelines for ultrasound services

When the advanced imaging utilization management program initially began, ultrasound cases required a prior authorization request be submitted on the same day services are provided. In an effort to allow greater flexibility, we’ve increased the authorization submission timeline for ultrasound services to two full business days from the date of service. For example, when an ultrasound is performed on Monday at noon, the prior authorization request may be submitted any time before end of business Wednesday.

Waiver period extension for Therapy and Alternative Care services

Previously, the Therapy and Alternative Care utilization management programs required a waiver period extension request if services were not provided within thirty days of the initial authorization request. We understand this time period may be too restrictive. To prevent potential disruption of care for Moda members, and to reduce potential administrative burden on your office, we’ve extended the initial time period allowed to provide approved visits to sixty days . This change does not impact the total approved number of visits for that time period.

We appreciate the input from our employer group and provider partners as we fine tune our prior authorization programs. 

To submit prior authorization requests for services included in the advanced imaging and therapy utilization management programs, please call eviCore at 844-303-8451. Prior authorization requests may also be placed online by visiting www.evicore.com

We’re here to help. To learn more about Moda’s utilization management programs, visit www.modahealth.com/medical/utilizationmanagement.shtml . Or, contact our customer service department at 877-605-3229.
Site of Care - specialty infusion program

Moda Health partners with Magellan Rx Management (Magellan Rx) for medical pharmacy management, including the provider-administered injectable medication and claim edit programs, to ensure our members receive quality and affordable care.

Effective Oct. 1, 2017 , our partnership with Magellan Rx will expand to include a Site of Care program that directs members to the most cost-effective, yet clinically appropriate, location to receive their infusion(s) of select specialty medications . The Site of Care program will apply to all fully insured commercial members and to all EOCCO members who begin using these medications on or after Oct. 1. Members currently using these medications will be subject to the Site of Care program requirements upon prior authorization renewal on or after Oct. 1, and were notified of this change by Aug. 1, 2017.

Through the current prior authorization program administered by Magellan Rx, infusion requests for a hospital outpatient setting for certain medications will be redirected to a preferred site of service, which will be either preferred home infusion providers or a professional office setting. Infusions for these medications will not be covered when administered in a hospital outpatient infusion center.

The drugs included in the Site of Care program already require prior authorization through Magellan Rx. The Site of Care program requirements will be administered as part of the existing prior authorization program. As a reminder, Moda will deny services as provider responsibility when prior authorization is not obtained for any medications that require prior authorization.

To learn more about our Site of Care program and to find the most up-to-date list of medications included in the program, please visit www.modahealth.com/medical/siteofcare .
Provider directory outreach

On Jan. 1, 2017 , the Centers for Medicare and Medicaid Services (CMS) published rules requiring that health insurers who offer Medicare Advantage plans reach out to each of its Medicare Advantage contracted providers on a quarterly basis to verify and update provider demographic information. As outlined in Chapter 4 of the Medicare Managed Care Manual, these requirements ensure that Medicare Advantage members have access to the most accurate and up to date information when searching for an in-network provider. The types of provider information we are required to validate include:

  • Practicing location
  • Accepting new Medicare patients status
  • Phone number
  • Provider specialty

In order to meet the new requirements set by CMS to maintain an accurate online provider directory, Moda Health has adopted a roster and phone validation process:

  • Rosters: Moda Health is reaching out to each of its provider groups with five or more practitioners and requesting an updated provider roster each quarter. Provider groups may submit the requested information in either of two formats: 1) Moda Health’s standard provider roster or 2) the OHLC roster template created by the Oregon Health Leadership Council. The OHLC roster was created with the aim of easing the administrative burden on provider practices by also being available and accepted by other health plans in Oregon. Rosters are collected each quarter.

  • Phone validation: Moda Health is reaching out to each of its provider groups with fewer than five practitioners and validating the provider information over the phone. This allows us to quickly validate and update provider information for provider groups with fewer practitioners. Phone validation is performed each quarter.

Moda Health appreciates your cooperation in helping us maintain CMS compliance and an accurate online provider directory.

For more information on these requirements, or if you have updates to your organization’s demographic information, please email your region’s Provider Services Rep.

To locate the Provider Services Rep for your region, visit www.modahealth.com/medical/find-your-rep.shtml .
Facility reimbursement of respiratory therapy services

Beginning Oct. 1, 2017 , reimbursement for respiratory therapy and ventilator management services that are provided in an inpatient hospital setting for all commercial, Medicare Advantage and EOCCO plans will be limited to one unit/charge per each date of service. Additional units or charges for the same date of service will not be eligible for separate reimbursement regardless of the description variation, HCPCS codes or revenue codes used.

  • Respiratory therapy services may include methods to support oxygenation and ventilation of an acute illness, such as establishing and maintaining an artificial airway, ventilator therapy, bronchial hygiene therapy and the periodic assessment of the respiratory therapy intervention.

  • Ventilator management services may be billed for patients on a ventilator, CPAP or BiPAP machine for any portion of the day outside of the operating or recovery room. Ventilator management services performed by a respiratory therapist may include evaluations and assessments or modifications to ventilator settings due to a change in a patient’s condition.

  • Some respiratory and ventilator services are not separately billable or eligible for separate reimbursement because they are considered part of the therapy. These services may include ventilator adjustments performed by a registered nurse, respiratory assisted equipment changes and patient screenings for sleep apnea.

Moda Health’s Facility Reimbursement of Respiratory Therapy Services Reimbursement Policy can be found here.
Payment Disbursement Register and 835 ERA overpayment enhancements

We’d like to inform you of some enhancements we’ve made to your Payment Disbursement Registers (PDR) and 835 ERA files. Based on feedback from providers like you, we’ve identified several areas in which additional claim payment and check detail could be provided to help your practice run smoothly.

Beginning in early August, claim-specific overpayment deduction details have been added to the PDR, including:

  • Original claim ID
  • Patient account number
  • Original paid date
  • Original check number
  • Original paid amount
  • Overpayment amount
  • Previously recovered amount
  • Current recovered amount
  • Remaining overpayment amount
In addition, 835 ERA files will now include the original claim ID and patient account number.

We hope these changes save time and improve patient account identification when your practice is identifying overpayment deductions. To view a sample of the new PDR, please visit www.modahealth.com/pdfs/pdr_guide_med.pdf .

For more information on your Payment Disbursement Register or 835 ERA files, please email medical@modahealth.com or call us toll-free at 877-605-3229.
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

2017 Provider workshops are just around the corner

Authorization extensions in eviCore's utilization management program

Site of Care- specialty infusion program

Provider directory outreach

Facility reimbursement of respiratory therapy services

Payment Disbursement Register and 835 ERA overpayment enhancements

Medical necessity updates
Go digital today!

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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