Oregon |March/April 2018
Clinical editing and administrative policy updates

Moda Health medical claims processing includes the use of clinical edits that follow CMS/Medicare coding guidelines, as well as other industry standard guidelines (including but not limited to AMA, CPT, HCPCS) for the appropriate adjudication of claims.

In an effort to reduce healthcare waste and billing errors, Moda Health will be standardizing clinical editing and reimbursement policies to more closely follow CMS for all lines of business, and enhancing the way clinical editing is applied to professional and facility claims.

Effective with processing dates of July 1, 2018 and after (regardless of the date of service) , Moda Health will be broadly implementing the following clinical edits for all our lines of business:

Multiple Procedure Payment Reductions – Multiple procedure adjustment rules will follow CMS for all types of multiple procedure indicators. Adjustments will be applied whether or not modifier 51 is appended to the procedure code. These include:

  • Multiple Procedure Reductions (CMS multiple procedure indicator “1” or “2”)
  • Multiple Endoscopy Reductions (indicator “3”)
  • Multiple Diagnostic Imaging Reductions (indicator “4”)
  • Multiple Therapy Reductions (indicator “5”)
  • Multiple Diagnostic Cardiovascular Reductions (indicator “6”)
  • Multiple Diagnostic Ophthalmology Reductions (indicator “7”)

More information on multiple procedure payment adjustments can be found on reimbursement policy RPM022 .

Discontinued Outpatient Hospital/ASC Procedures (Modifiers 73 & 74) – CMS requirements and adjustments for discontinued procedure facility fees will be applied. More information can be found on reimbursement policy RPM049 .

Anesthesia Payment Modifiers - Anesthesia services must be submitted with an appropriate anesthesia payment modifier to indicate the number of providers and roles involved in the anesthesia service. Please begin submitting modifier AA when services are performed personally by an anesthesiologist. CMS reduction rules for modifier AD will be applied. 

Effective for claims processed on or after July 1, 2018, regardless of date of service, claims for anesthesia services submitted without an appropriate payment modifier will be denied as a billing error for lack of a required modifier. A corrected claim will need to be submitted with the appropriate modifier(s) added. More information can be found on reimbursement policy RPM034 .

Maternity Global Periods – The global maternity period for vaginal delivery will be 49 days. The global maternity period for cesarean delivery will be 90 days, which is the same as any other major surgery. More information can be found on reimbursement policy RPM020 .

Medicare Advantage Claims – As a reminder, CMS documents a wealth of very specific coding and coverage requirements in National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs, e.g. Noridian LCDs), transmittals, MLN articles, and other sources. Remember that if CMS requires that a certain procedure code, value code, provider specialty, condition codes, bill type, etc. be used, these requirements need to be followed, as they apply to Medicare Advantage claims as well.

Over the next few months, we’ll be sending you more information on our clinical editing and administrative policies, and offering educational resources to your practice that include tips on modifier usage, documentation rules, and coding guidelines.

As we continue to focus on our commitment of more closely aligning our policies with CMS guidelines and being transparent with our provider partners, we’d like to thank you for your continued efforts of following correct coding and billing practices.

To view a complete list of Moda’s reimbursement policies, please visit www.modahealth.com/medical/policies_reimburse.shtml .
New red, white, and blue cards with Medicare Beneficiary Identifier (MBI)

The Centers of Medicare and Medicaid Services (CMS) will begin issuing new identification cards to all Medicare beneficiaries, beginning between April 2018 and April 2019.

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

CMS’s 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.  

More information on the new Medicare Beneficiary Identifier can be found here.
National Prescription Drug Take Back Day

The next biannual National Prescription Drug Take Back Day will be held on April 28 th, 2018.  This is a great opportunity to encourage your patients to bring expired or unused prescription medications for proper disposal at the various drug take back sites.

The public health hazard of medication stockpiling has gained great momentum since the Secure & Responsible Drug Disposal Act of 2010 [1] .  Patients are often uncertain how to properly dispose of unused medications.  Some intentionally save unused prescription medications for later use at their own discretion. The biannual National Prescription Drug Take Back Day serves as a great avenue for proper disposal of prescription medication stockpiles.  Some patients may not be able to take advantage of that resource, therefore it is crucial that patients are also educated throughout the year by their healthcare professionals.

Why should I encourage my patients to dispose of their prescription drugs at a designated site?

  • After the expiration date, the manufacturer cannot guarantee the full potency and safety of the drug. Thus, it may not work as intended and has the potential to cause undue harm.
  • Keeping expired or unused prescription drugs increases the likelihood misuse or abuse.
  • Failing to dispose of these medications may lead to accidental poisoning and overdose in children, pets, and other members of the household.
  • Proper disposal is better for the environment than throwing in the garbage or flushing down the toilet, which can cause contamination of streams and drinking water.

Resources and disposal sites for your patients:

[1] Secure and Responsible Drug Disposal Act of 2010, S. 3397, 111 th Cong. (2010). Retrieved from GPO’s Federal Digital System: www.deadiversion.usdoj.gov/drug_disposal/non_registrant/s_3397.pdf
Medical necessity updates

We've recently added several new codes to our prior authorization list. See our current list of prior authorization services  here .
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

Clinical editing and administrative policy updates

New red, white and blue cards with Medicare Beneficiary Identifier (MBI)

National Prescription Drug Take Back Day

Medical Necessity updates
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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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