Oregon |July/August 2018
Individual plan changes coming in 2019

With 2019 open enrollment coming soon, we would like to share some important changes to Moda Health’s individual plans that are available to Oregon individual members purchasing health coverage directly from Moda or through the federal marketplace exchange.

  • Beginning Jan. 1, 2019, all Oregon individual plans that include Beacon EPO, Affinity EPO, and Cornerstone EPO, will be connected to an Exclusive Provider Organization (EPO) network.
  • Individual EPO plans do not have out-of-network benefits, so it is important that your patients are referred to specialists and other providers within the individual plan and network they are enrolled in.
Please review your patient’s Moda member ID card and check our provider directory, Find Care, to ensure care is referred to in-network Beacon, Affinity, or Cornerstone providers. Services provided to Moda individual members by out-of-network providers will result in higher costs for patients enrolled in these plans.
All individual EPO plans require that a member select a primary care provider (PCP) within the network they are enrolled in. A member’s PCP works closely with the rest of their care team (other providers, specialists, etc.) to help them achieve better health and wellness.
Please see our Networks page to learn more about Moda’s plans and networks.
Please call us toll-free at 877-605-3229 or email medical@modahealth.com .
New online prior authorization platform

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 organization’s electronic health record system, or directly through the CoverMyMeds portal.
Starting Sept. 6, 2018, prescribers and staff can start using CoverMyMeds to submit ePA requests that utilize Moda’s custom criteria and question sets for Moda Commercial and EOCCO members. CoverMyMeds provides a convenient and streamlined prior authorization process that supports faster determinations and an automatic renewal setup that supports medication adherence for your patients.
If you currently use CoverMyMeds, the system will be updated on Sept. 6 with custom prior authorization criteria and question sets for members enrolled in select Moda Health plans. New to CoverMyMeds? To get started, create a free account today at the CoverMyMeds website .
Weekly webinar trainings are also available at go.covermymeds.com/moda . CoverMyMeds is happy to schedule webinars at a day and time that’s convenient for you. Please email help@covermymeds.com or request a date and time for a demo at covermymeds.com . Learn more at go.covermymeds.com/moda.
Reduce drug waste with MagellanRX

In an effort to improve the quality of care for our members, Moda is partnering with MagellanRx on a new program to help reduce drug waste. Beginning Oct. 1, 2018 , the Provider Administered Drug Program that’s managed by MagellanRx Management will be enhanced to help provide the most efficient dosage for select buy and bill drugs. 
When authorization is requested for these drugs, a recommendation to adjust dosages to the nearest vial size combination will be made as appropriate. The online portal (or intake specialist, if phoning in the prior authorization) will display the most efficient vial size combinations that should be utilized. Acceptance of these recommendations is completely voluntary and adjustments should be made at the ordering physician’s discretion.
The goals of this new program are: 

  • To reduce waste
  • Assist providers with inventory management
  • Lower the overall cost of healthcare
A complete list of the drugs included in drug waste program can be found here.
Meeting your Medicare compliance requirements

We take compliance seriously at Moda Health, and we appreciate that you do, too.
The Centers for Medicare & Medicaid Services (CMS) requires healthcare providers and facilities that contract with Medicare Advantage Plans, like Moda Health, to complete Medicare compliance requirements throughout the year. Moda asks our contracted providers and facilities to complete an annual Medicare Compliance Attestation to demonstrate that the provider or facility completed its Medicare compliance requirements.
Moda’s Medicare Compliance Program website is available to all contracted providers and facilities.
For questions about the program, email our Medicare Compliance team at delegatecompliance@modahealth.com
eviCore online resources

eviCore healthcare and Moda Health understand that requesting prior authorization for services can be difficult to understand. To help your practice save time, eviCore offers helpful tips and education that help ensure your prior authorizations are complete and accurate. eviCore’s suite of online resources include:

  • Clinical guidelines
  • Quick reference tools with contact phone/fax and web portal directions by solution (radiology, cardiology, musculoskeletal)
  • Important forms
eviCore webinars also cover a variety of topics to help you with the prior authorization pathway. During these sessions, eviCore's provider experience team will provide an overview of the following:

  • Program details for radiology, cardiology and musculoskeletal
  • Methods of requesting prior authorization
  • Additional tools and education materials

Learn more online at eviCore’s provider resources page . For questions, email clientservices@evicore.com .
Help your patients fight the flu

The flu season is approaching and it’s time to help your patients take preventative action. Although the severity can vary year-to-year, according to the CDC millions of illness and tens of thousands of flu-related deaths have occurred since 2010.
In February, estimates of vaccine effectiveness by the U.S. Flu Vaccine Effectiveness Network showed vaccinations reduced the overall risk of respiratory illnesses by 36% in 2018. Getting a flu shot can offer substantial benefits and reduce the likelihood of severe outcomes including hospitalization and death.
The CDC recommends:

  • Flu vaccines for all persons six months and older.
  • Emphasis should be place on high-risk groups, such as:
  • Children aged 6-59 months
  • Adults aged > 50 years
  • Women who are or will be pregnant during the flu season
  • Persons with chronic conditions, or are extremely obese

  • FluMist Quadrivalent (LAIV4) versus inactivated influenza vaccine (IIV)
  • The American Academy of Pediatrics (AAP) recommends inactivated influenza vaccine (IIV3/4) as the primary choice for all children for the 2018-19 season because the effectiveness of LAIV4.
  • The FluMist Quadrivalent (LAIV4) as an option for flu vaccines. No estimates on vaccine effectiveness are available for the new formulation of LAIV4.

Remember that flu vaccines are typically covered under the pharmacy benefit. Pharmacists are able to administer flu shots to patients age seven years and older. Most members may qualify for a $0 copay.
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

Individual plan changes coming in 2019

New online prior authorization platform

Reduce drug waste with MagellanRX

Meeting your Medicare compliance requirements

eviCore online resources

Help you patients fight the flu

Medical Necessity updates
Provider workshops just around the corner!

Moda's 2018 Medical Provider Workshops start Oct. 15, 2018. Sign up today for a workshop near you to l earn about our 2018 updates and get a glimpse of what's ahead for 2019.
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
Join our email list

Visit our website and click on "Join our email list" in order to begin receiving bi-monthly newsletters, as well as occasional electronic communications. 
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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