Oregon | March/April 2017 

eviCore now handling prior authorization requests

We would like to remind you that as of April 1, 2017, prior authorization requests for advanced imaging and musculoskeletal services now go through our new partner, eviCore healthcare. It is important to note, however, that not all eviCore programs apply to all Moda members. For example, musculoskeletal services do not require prior authorization for most ASO clients, Medicare or Medicaid members. To ensure you have the most up-to-date, member benefit information, please log in to Benefit Tracker.

This partnership is designed to meet the needs of Moda employer groups and members. Many details of the program have been specifically set to minimize the impact to our members or providers.

To support this transition, we will be tracking provider concerns and meeting weekly with eviCore to address these issues. As a valued provider partner of Moda Health, we look forward to an ongoing dialogue with you about this program.

To learn more about Moda’s utilization management programs, please visit our utilization management website or contact our customer service team at 877-605-3229.

Enhanced vision benefits now on EBT

We’re excited to share with you enhancements to our Enterprise Benefit Tracker (EBT) online tool and myModa.com. As a provider, you can now view additional benefit details on the utilization and eligibility for members enrolled in a vision plan. The new details include:

  • Vision benefit maximum
  • Vision benefit used
  • Vision benefit remaining
  • Next available benefit date

This information is also broken out in the following categories:

  • Lenses benefit detail
  • Contact lenses benefit detail
  • Single vision lens benefit

We hope these updates make it easier to identify current benefit availability, the next available date for benefit usage, and the vision maximum used when reviewing your patients’ vision benefits. 

To view your patients’ vision benefits, just visit Benefit Tracker and search for your patient. Then, click Vision Benefits in the patient’s benefit profile (as shown, below). For members who have vision benefits embedded in their medical plans, these enhancements will display under the Medical Benefits link.

Zarxio named preferred medication for G-CSF injections

As part of our commitment to providing members with high-quality affordable care, Moda Health has selected Zarxio as the exclusively preferred short-acting granulocyte colony stimulating factor (G-CSF) product. Members who receive G-CSF injections will be limited to the product unless deemed a medical necessity. Those currently receiving G-CSF injections with a non-preferred product may complete their course of therapy as it applies to the existing authorization period. 

Effective July 1, 2017, 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.

If there is clinical documentation that Zarxio is ineffective, not tolerated or should not be used, an alternate G-CSF product may be considered. Trial and failure of Zarxio is required by the plan before using other short-acting G-CSF products, unless it is a medical necessity. 

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. 

Get started today!

To begin requesting online prior authorizations through Magellan Rx, please visit the Magellan Rx self-service portal and 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 website.

We appreciate your support in assuring our members receive quality care. If you have questions, please call our customer service team at 877-605-3229.

Generic EpiPen now available to members

As you know, the price for EpiPen has jumped in recent years. While there are other products on the market, many still carry a high cost. In December 2016, the maker of EpiPen launched a non-branded product with a 50 percent lower wholesale cost than EpiPen.

The generic medical device is similar to EpiPen. However, because it is an authorized generic without an AB rating, prescriptions written for EpiPen may not be automatically replaced with the generic product at a pharmacy.

This non-branded formulation provides a new cost-effective alternative to the EpiPen that is similar from a safety and efficacy perspective. Please consider writing for the lower cost generic epinephrine auto-injector for your patients, which is now available to them at a lower cost share.

Billing vaccines: Single and combination codes

Moda Health knows there are many options for providing and billing vaccines. Many of the required vaccines have been combined as a single vaccine to limit the number of times a patient experiences the needle stick. We understand that sometimes the combination vaccine is not used, and instead single doses of several vaccines are given at one visit. Our system will rebundle the vaccines into a single combination code if one is available. To avoid re-bundling, the use of a separate and distinct modifier on either, but not both, of the single vaccine codes will allow the claim to process. 

For example, Hepatitis A (90632-90634) billed with Hepatitis B (90739-90747) will combine to 90636 unless the separate and distinct modifier is appended (e.g., 90632 and 90739-59 OR 90632-59 and 90739).

Please remember to use the separate and distinct modifier if giving single vaccines separately when a combination vaccine code is available. 

HEDIS measures for chlamydia screening

Chlamydia is extremely common. Providers have the greatest effect on minimizing the impact of chlamydia in a community. Be diligent on screening and treating chlamydia, and you will significantly reduce the morbidity of this disease in your patients.

Measure definition: This measure looks at the number of sexually active female Medicaid patients ages 16 to 24 (as of Dec. 31, 2017) who have been screened for chlamydia at least once in the measurement year.  

Why is this measure important?

Chlamydia is the most common bacterial STD in the U.S. When left untreated, up to 40 percent of cases will turn into pelvic inflammatory disease, leading to pelvic pain, infertility or ectopic pregnancy.[1] Antibiotics are highly effective in treating chlamydia.

Provider tips:

  • Make sure you are incorporating chlamydia screenings in your practice for patients who are sexually active up until age 25. This includes patients seen in pediatric practices.
  • Create a flag in EHR that’s attached to sexual activity that serves as a reminder for chlamydia screening.
  • Provide screenings for all women under age 25 who have a prescription for birth control.
  • Take a confidential sexual history with adolescent patients. It is important to normalize and destigmatize STIs.
  • Make chlamydia screening easier for women by offering a urine specimen for testing, rather than a vaginal swab.
  • Explain the complications of undiagnosed and untreated chlamydia, as well as ease of treatment when detected early.
  • If chlamydia is detected, counsel patients on future prevention. A patient is likely to be reinfected unless all of her partners are free of chlamydial infection.

Please contact us with any questions or concerns on this or any other HEDIS measure at HEDIS@modahealth.com.

(1)http://journals.lww.com/greenjournal/Fulltext/2000/03000/Direct_Medical_Cost_of_Pelvic_Inflammatory_Disease.16.aspx

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

eviCore now handling prior authorization requests

Enhanced vision benefits now on EBT

Zarxio named preferred medication for G-CSF injections

Generic EpiPen now available to members

Billing vaccines: Single and combination codes

HEDIS measures for chlamydia screening
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