Oregon |March/April 2019
Changes to reimbursement for DRG payments (RPM066)

We are making some changes that will affect how we reimburse Diagnosis Related Group (DRG) facilities when a Moda Health member is transferred from a DRG facility to a different acute care hospital.

For discharge and transfer service dates starting July 1, 2019 , when a DRG facility transfers an inpatient to a different inpatient hospital, the DRG facility will be paid a graduated per diem rate for each day of the patient’s stay in that hospital, not to exceed the DRG allowable amount. The per diem rate is based on a calculation defined by the Centers for Medicare and Medicaid Services (CMS).

A transfer occurs when a member:

  1. Transfers to a different acute care hospital for related care.
  2. Leaves against medical advice and is subsequently admitted to the same or different acute care hospital within 24 hours of leaving.
  3. Or is discharged, but then readmitted to another acute care hospital within 24 hours (unless the readmission is unrelated to the initial discharge)
 
To learn more, please see Moda Health’s DRG Payment with Patient Transfers Reimbursement Policy or a complete list of our reimbursement policies.
Reimbursement changes Anesthesia Modifiers (RPM032)

We are making some changes that will affect how we reimburse Anesthesia Physical Status Modifiers (P1-P6).

Effective for service dates starting July 1, 2019 , Moda Health will align with CMS’s reimbursement policies. These changes include:

  1. Moda Health will no longer provide additional reimbursement for Anesthesia Physical Status Modifiers P1-P6 billed on Moda Medicare Advantage claims.
  2. Moda Health will not provide additional reimbursement for Anesthesia Physical Status Modifiers P1-P6 billed for OHP/EOCCO claims as modifiers P1-P6 are bundled in the payment for codes 00100-01999.

Moda Health will continue to provide additional reimbursement for Anesthesia Physical Status Modifiers P3-P5 that are billed on Commercial claims.

To learn more, please see Moda Health’s Anesthesia Physical Status Modifiers Reimbursement Policy or a complete list of our reimbursement policies.
Biosimilar products are safe, effective and cost-saving

The development of biologics has changed how we treat many common conditions such as autoimmune diseases and cancer. They are large molecules produced from living organisms. This process is more complex and expensive than conventional, small molecule drugs. Therefore, making a copy of a biologic (or “biosimilar”) is different from creating a generic version of a small molecule drug.
 
Biosimilars offer many benefits to patients, providers, and the healthcare system. They provide additional product options for patients and increase access to treatment. Increased competition results in reduced costs for the healthcare system and patients. Current projections indicate biosimilar products are expected to cost an average of 10% to 40% less than their reference products.
 
As biosimilar products enter the market, it is important to understand the biosimilar approval process so patients and providers have confidence in these safe, effective and cost-saving therapies. Learn more by choosing any of the following resources:

Injectable medication expansion

The following prior authorization updates have been made to the injectable medications currently in the MagellanRX 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

Effective July 1, 2019

  • Velcade (J9041) – Primary cutaneous T-cell lymphoproliferative disorder will be removed as a covered indication.
 
Effective August 1, 2019

  • Abraxane (J9264) – Uterine cancer, uveal melanoma, and subsequent treatment of advanced NSCLC will be removed as covered indications. Limited treatment in HER2-positive breast cancer to first-line therapy and use in HER2-negative disease to subsequent therapy.
  • Marqibo (J9371) – Use in Philadelphia chromosome positive acute lymphoblastic leukemia will be removed as a covered indication.
  • Onivyde (J9205) – Coverage is provided following prior gemcitabine-based therapy, use after fluoropyrimidine-based therapy will be removed as a covered indication.
  • Yondelis (J9352) – Use in angiosarcoma will be removed as a covered indication, and use in rhabdomyosarcoma has been limited to translocation-related sarcoma subtypes.
  • Halaven (J9179) – Use is HER2-positive breast cancer will be removed as a covered indication. The soft tissue sarcoma subtypes angiosarcoma and pleomorphic rhabdomyosarcoma will be removed as covered indications. 

Learn more about the injectable medication program and view the current medication list .
Medical necessity criteria updates

We've recently updated our medical necessity criteria. You can find the following changes at our  medical necessity criteria page.

Effective April 1, 2019


Effective May 1, 2019


Effective June 1, 2019

Effective July 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

Changes to reimbursement for DRG payments (RPM066)

Reimbursement changes for Anesthesia Modifiers (RPM032)

Biosimilar products are safe, effective, and cost-saving

Injectable medication expansion

Medical necessity criteria updates
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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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