Oregon | November/December 2016 

Network updates for individual (non-group) members

As the end of open enrollment nears, we want to make sure you are clear about changes to plans available to individuals purchasing health coverage directly from Moda Health or through the federal marketplace.

Eastern Oregon
January 1, 2017, the Beacon Network name will be replaced by the Affinity network in Eastern Oregon. This network will be available to individuals and families in Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa and Wheeler counties. Affinity members will have access to several hospital systems including Blue Mountain Hospital District, Good Shepherd, Grande Ronde Hospital, Harney District Hospital, Lake District Hospital, Pioneer Memorial Hospital (Heppner), St. Alphonsus Baker City, St. Alphonsus Ontario, St. Anthony Hospital and Wallowa Memorial Hospital.

Western Oregon
Beginning January 1, 2017, Beacon plans will be accessible only to individuals and families who reside in 14 counties: 
Clackamas, Clatsop, Columbia, Coos, Curry, Hood River, Jackson, Josephine, Marion, Multnomah, Polk, Yamhill, Washington and Wasco. Moda has partnered with 9 Beacon network health systems: Asante, Bay Area Hospital, Columbia Memorial, Mid-Columbia, OHSU, Portland Adventist, Salem Health, Tuality and Willamette Valley Medical Center. The Beacon network will focus on improving health outcomes through clinical integration enabling hospital system partners and Moda Health to ensure high-quality, high-value care.

Curry General Hospital and Providence Health and Services - Medford will also participate in the Beacon network for 2017.

Counties without a Moda individual option
Moda will continue to be an option to individuals and families residing in most of the state. There will, however, be 10 counties where Moda will not offer an individual plan: Benton, Crook, Deschutes, Douglas, Jefferson, Klamath, Lane, Lincoln, Linn and Tillamook.

Please note that this applies only to individuals and families purchasing coverage directly from Moda or through the marketplace. These changes have no effect on members covered under employer group plans, Medicare or Medicaid. 

Still have questions about Moda's provider networks? Email us at providerelations@modahealth.com .  

PCPCH tier expansion

Administered through the Oregon Health Authority (OHA), the Patient Centered Primary Care Home  (PCPCH) program promotes and bolsters primary care initiatives in support of achieving the Triple Aim: Better health, better care, and lower costs. As a participating PCPCH certified Moda Medical Home , we appreciate and value your dedication to making sure Oregonians have access to quality, comprehensive care.

Beginning  January 1, 2017 , the OHA will expand PCPCH recognition standards from four levels to five as a way to identify and distinguish clinics that implement advanced, primary-care practices.

Under the 2017 criteria, clinics applying for PCPCH recognition for the first time in 2016 will be recognized through December 31, 2016, and must reapply in January 2017 under the revised standards. PCPCHs due to re-apply for recognition in 2016 under the current model standards will be granted an extension of their PCPCH recognition until January 1, 2017, and includes a 30-day grace period. PCPCHs choosing to reapply for recognition in 2016 under the current 2014 standards will be recognized through December 31, 2016, and must reapply in January 2017 under the revised standards.

To learn more about the OHA's 2017 PCPCH recognition criteria, and to apply under the revised PCPCH program, visit www.primarycarehome.oregon.gov or email pcpch@state.or.us

Prior authorization policy reminder

Effective January 1, 2017 , for all in-network individual, ASO, small and large group plans, Moda will deny services if required authorization is not obtained before rendering the service. If a prior authorization is not obtained for in-network services, Moda will deny charges as provider responsibility.

All services that require authorization and are denied due to failure to obtain prior authorization may be identified on the Provider Disbursement Register by EXCD codes 134, 135, 20M, UM0 and M21. This list could include additional denial codes in the future.

If you have members who use an out-of-network provider, the member is responsible for ensuring their provider contacts Moda for prior authorization. If prior authorization is required but not obtained for a member seeking services from an out-of-network provider, the services may be denied and the member may be responsible for the charges.

Services that require prior authorization, as well as contact information, can be found at www.modahealth.com/medical/referrals/

Updated clinical guidelines

The Moda Healthcare Services team provides medical management for serious illnesses, as well as coaching  and outreach to help keep members healthy and informed. Moda Health coaching, care coordination, case management and behavioral health programs are developed using nationally recognized, evidence-based clinical guidelines. 

We offer several medical management guidelines addressing:

  • High blood pressure in adults 
  • Adult depression in primary care
  • Routine prenatal care
  • Assessment and management of chronic pain
  • Tobacco cessation

You will also find guidelines for behavioral health treatment such as recommendations for the assessment and treatment of adjustment disorder, and for using outcome measures in outpatient psychotherapy.

Clinical guidelines for disease management and preventive screenings can be found online at www.modahealth.com/medical/clinical_guidlines_tools.shtml.

Additional resources for behavioral health clinical guidelines can be found at www.modahealth.com/medical/behavioral_health.shtml. 

To learn more about Moda's medical management and health coaching programs, contact Moda Health Coaching at 877-277-7281, or emai l careprograms@modahealth.com

HEDIS measure: Appropriate testing for children with pharyngitis

Measure definition:
The percentage of children 3 to 18 years of age diagnosed with pharyngitis, dispensed an antibiotic and who received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing) 
[1] .

Why is this measure important?

Pharyngitis is the only condition among upper respiratory infections (URIs) where diagnosis is validated easily and objectively through administrative and laboratory data. It can serve as an important indicator of appropriate antibiotic use among all respiratory tract infections. A throat culture or strep test should be administered as an indicator for appropriate antibiotic use. Unnecessary prescription of antibiotics can lead to antibiotic resistance 
[2] .

Provider tips when talking to the patient:

  • Perform a strep test to confirm diagnosis before prescribing antibiotics
  • If the patient or caregiver refuses testing, document in medical record
  • If strep test is negative, educate patients and parents on the risks of antibiotic resistance
  • Educate them on the difference between bacterial and viral infections
  • Educate patients and caregivers on ways to prevent infection

1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS 2017 Technical Specifications for Health Plans (National Committee for Quality Assurance 2017), 94-97
[2]  National Committee for Quality Assurance (NCQA). HEDIS 2015 technical specifications for ACO measurement. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.  www.qualitymeasures.ahrq.gov/summaries/summary/48816

HEDIS measures: Appropriate treatment for children with URI and avoidance of antibiotic treatment in adults with AAB

HEDIS Measure Definitions:
Appropriate treatment for children with upper respiratory infection (URI): The percentage of children 3 months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription 
[3] .
Avoidance of antibiotic treatment in adults with acute bronchitis (AAB): The percentage of adults 18 to 64 with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription  [4]. 
Why are these measures important?
One of the most common reasons children visit their medical provider is for the common cold or non-specific URI. According to the Centers for Disease Control and Prevention, at least 200 viruses can cause the common cold, and most URIs are viral. Pediatric clinical guidelines do not recommend antibiotics for URIs that are viral, however some providers still prescribe them. Antibiotics should be prescribed only when necessary. Patients and the community can benefit from education  [5]. 
Provider tips when talking to patients or caregivers:
  • Educate patients and caregivers on URIs, also known as common cold and which require no antibiotic treatment
  • Explain that unnecessary antibiotics can promote long-term antibiotic drug resistance and unintended adverse outcomes
  • The CDC offers "Get Smart" brochures you can provide patients at no cost
  • If the patient or caregiver insists on antibiotics, discuss side effects
  • Use proper diagnosis code if prescribing an antibiotic for a bacterial infection
  • Encourage best practices on proper hand washing and covering a cough
  • Advise patient to contact primary care provider if symptoms worsen
[3] HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS 2017 Technical Specifications for Health Plans (National Committee for Quality Assurance 2017), 210-212
[4] HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS 2017 Technical Specifications for Health Plans (National Committee for Quality Assurance 2017), 213-217
[5] Center for Disease Control and Prevention (CDC). 2017 Pediatric Treatment Recommendations. www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html

Medicare outpatient observation notice

On August 6, 2015, Congress enacted the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act. This requires all hospitals and critical access hospitals (CAHs) to provide written notification and an oral explanation of such notification to individuals receiving observation services as outpatients for more than 24 hours.

The purpose of this memorandum is to announce the availability of the OMB-approved standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611. All hospitals and CAHs are required to provide this statutorily required notification no later than March 8, 2017. The notice and accompanying instructions are available at: www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html.

The MOON was developed to inform all Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH. In accordance with the statute, the notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services. Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated, or sooner if the individual is transferred, discharged or admitted.

Expedited vs. standard requests

CMS guidance states that a Medicare health plan expedite an organization determination when the enrollee or their physician believes that waiting for a decision under the standard time frame could place the enrollee's life, health or ability to regain maximum function in serious jeopardy. The standard timeframe is 14 days, but Moda processes requests as expeditiously as the member's condition requires. If you have a scheduling issue where you have a pressing need, but your patient does not meet the "expedited" medical urgency standard, please call Medicare Authorization at 800-592-8283

Requesting authorizations for Medicare Advantage patients

When requesting an authorization for your Medicare patients, please use the  Medicare Authorization form  to make sure your request reaches the correct department. You can also find the Medicare Authorization form on our website under the "I'm a Provider" section. Then select Medical provider, Provider resources and Forms.  

When you are ready to submit authorization for a Medicare patient, you may fax your request to 855-637-2666 , or mail to:

Moda Health
Attn: Medicare Authorization Department
P.O. Box 40384
Portland, OR 97240
For questions, please call us at 800-592-8283 .

Coding for Medicare routine physicals

All Medicare Advantage plans must comply with all the statute and regulations in the Code of Federal Regulations, CMS National Coverage Determinations, as well as the local coverage determinations (LCD) from MACs with jurisdiction over the plan's service area. The Initial Preventive Physical Exam (IPPE) and the Annual Wellness Visit (AWV) are covered services under Original Medicare. They are also covered by Moda Health Medicare Advantage plans. Correct coding for these visits is explained in this CMS article .

Please advise your billing offices not to bill Moda for a routine annual physical exam with code 99397. Moda's Medicare Advantage plans are not filed to offer this benefit as a mandatory supplemental benefit and, therefore, are not covered under our plans. 

Referring your patient to a non-contracted provider

If you are sending your patient to a provider outside of Moda's Medicare Advantage network, please make sure services are covered under the plan. If you are unsure, you must request an organization determination on behalf of the patient so your patient is not left with unexpected cost.   

To request an organizational determination, visit or call our customer service team at 800-258-2037.

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

Network updates for individual (non-group) members

PCPCH tier expansion

Prior authorization policy reminder

Updated clinical guidelines

HEDIS Measure: Appropriate testing for children with pharyngitis

HEDIS Measure: Appropriate treatment for children with URI and avoidance of antibiotic treatment in adults with AAB

Medicare outpatient observation notice

Expedited vs. standard requests

Requesting authorizations for Medicare Advantage patients

Coding for Medicare routine physicals

Referring your patient to a non-contracted provider
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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
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.

Medical Necessity updates

We've recently made an update to the Intervertebral Disc Prosthesis medical neccessity criteria.
You can find a complete list of medical necessity criteria changes online at modahealth.com.

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