Oregon | November/December 2017 
2018 Network updates

With the 2018 plan year almost here, we want to make sure you are up to speed with changes to Moda Health’s Beacon and Affinity plans. These plans are available to Oregon individual members purchasing health coverage directly from Moda or through the federal marketplace.

Effective Jan. 1, 2018 , Moda Health will partner with St. Charles Health System, Sky Lakes Medical Center and PeaceHealth to offer expanded coverage of the Affinity Network in Crook, Deschutes, Jefferson, Klamath and Lane counties. In addition, we’ve partnered with Tillamook Regional Medical Center to offer expanded coverage of the Beacon Network in Tillamook County.

These changes do not impact our small and large group plans. The geographic availability of Connexus, Synergy and Summit networks will remain the same for the 2018 plan year.

The Beacon and Affinity networks will continue to drive the goal of achieving the Quadruple Aim –– better health, better care, better value, with provider engagement.
To learn more about Moda Health’s medical provider networks, please call 877-605-3229 or email us at medical@modahealth.com.
Servicing facility documentation

Beginning Jan. 1, 2018 , a new federal requirement applies to Moda members on individual and small group plans. Incurred out of network cost sharing must be applied to the member’s annual in-network out-of-pocket benefit maximum when services are performed by an out-of-network ancillary provider in an in-network facility.

In response to this federal mandate, we ask that you complete the Servicing Facility Location Information (box 32) of the CMS-1500 claim form, with the facility’s name, address, and NPI so that we may more accurately monitor these scenarios.

If the Service Facility Location Information is not completed, the claim will be denied with EX code 7AF “service facility location is missing,” and a corrected claim will need to be submitted.
If you have questions related to Servicing Facility Location Information claim form requirements listed above or Denial Code 7AF, please email medical@modahealth.com or call 877-605-3229.
Authorization for ultrasound services no longer required

On April 1, 2017, Moda Health transitioned its utilization management programs for advanced imaging and musculoskeletal services to eviCore healthcare. Utilization management helps make sure that patients get the highest quality care. It also helps make sure that they do not pay for services or treatment they don’t need. With the transition to eviCore, we have been able to offer utilization management for more services. One such example is the ultrasound program, which includes both OB-GYN and Non-OB-GYN ultrasounds.

As a learning organization, we continuously evaluate our performance and that of our programs. Now, almost seven months after using eviCore, data has come out revealing Oregon practice patterns that differ from those seen at a national level. After careful consideration of this data, as well as the impact on our providers and members, we have elected to stop using the eviCore prior authorization program for ultrasounds only. Effective Jan. 1, 2018 and applicable to all commercially insured and EOCCO plans, prior authorizations for ultrasounds, either OB-GYN or Non-OB-GYN, will no longer be required.

To learn more about Moda’s utilization management programs, visit  www.modahealth.com/medical/utilizationmanagement.shtml. You may also call our Customer Service team at 877-605-3229.
Oral appliance billing

Participating medical or dental practices who provide Moda members with oral appliances for treating obstructive sleep apnea, we want to remind you of the service and claim documentation required for oral appliance billing.

Applicable to all Commercial, Medicare Advantage and OHP/EOCCO plans, Moda Health requires the following documents for Oral Sleep Apnea Devices (E0486) remain on file and be supplied for review upon request.

What’s needed?
  • A copy of the original physician request, order or prescription for the oral sleep apnea device
  • A copy of the insurance preauthorization approval
  • A description of the item or appliance, including documentation to support that the appliance was custom-fabricated and fitted to the patient, with adjustments if necessary
  • Proof of delivery to the patient

To view Moda Health’s Oral Sleep Apnea Device/Appliance Documentation Reimbursement Policy, please visit www.modahealth.com/pdfs/reimburse/RPM055.pdf.

Learn more about Moda Health’s reimbursement policies online at www.modahealth.com/medical/policies_reimburse.shtml or email us at medical@modahealth.com .
Online referral and authorization guidelines

Moda Health’s online referral and authorization guidelines for Commercial, Medicare Advantage and PERS plans are available to help you determine what procedures and services need prior authorization, which services are always not covered or those that are not medically necessary.

Procedures and services included on the Medicare Procedures and services requiring prior authorization and Commercial Group/Individual 2017/2018 group/individual prior authorization list always require authorization prior to providing the service. If authorization is not obtained prior to rendering the service, Moda will deny charges as provider responsibility.

Procedures and services included on the Commercial 2017/2018 group/individual always not covered list are considered investigational or cosmetic, and will not be covered by your patient’s benefits.

All services that require prior 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. Please note, this list may be expanded to include additional denial
codes in the future.
If you have members that use an out-of-network provider, please be aware that the member is responsible for ensuring that 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.

For more information on Moda Health’s referral and authorization guidelines, please visit www.modahealth.com/medical/referrals/ or call our Customer Service team at 877-605-3229. You may also email us at medical@modahealth.com.
NCQA recommendations for breast cancer screenings

Women age 50-74 years old should receive a mammogram at least once every two years. Physicians need to identify higher-risk members for earlier or more frequent screenings.

Determinants of breast cancer screening uptake:

Physician recommends mammography and assists in scheduling

Action : Train scheduling staff to identify eligible patients before appointments and assist in scheduling mammogram before patients leave the clinic. Consult with your EHR provider to see if flags can be built into your system.

Patients understanding their risk. Many patients do not believe they are at risk due to a lack of family history or not presenting symptoms.

Action : Discuss a mammography schedule with every eligible patient and explain the risks and benefits of screening.

Patients’ fears being addressed. Many patients are fearful of pain, embarrassment and cancer detection.

Action : Discuss ways to ease discomfort during a mammogram, such as avoiding caffeine and using topical numbing creams. Explain that early detection means a very high survival rate.
Medication stockpiling update
The public health hazard of medication stockpiling has gained great momentum since the Secure and Responsible Drug Disposal Act of 2010 [1] . Patients are often uncertain how to properly dispose of unused medication. Some intentionally save unused prescription medications for later use at their own discretion. While the biannual National Prescription Drug Take Back Day organized by the Drug Enforcement Administration (DEA) encourages the proper return and disposal of prescription medication stockpiles, 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 of 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: https://www.deadiversion.usdoj.gov/drug_disposal/non_registrant/s_3397.pdf
Preferred drug program authorizations
Beginning Jan. 1, 2018 , generic glatiramer acetate and Glatopa will no longer require prior authorization for all ASO and Commercial fully insured plans. A small number of prescriptions may be stopped for prior authorization review as this update is being implemented, however these claims will promptly be approved by our pharmacy staff.

Please note that brand Copaxone still requires prior authorization.

More information on Moda Health’s Preferred Drug Program can be found here . You may also call our Moda Health Pharmacy Customer Service at 888-361-1610.
New codes added to prior authorization list

We've recently added several new codes to our prior authorization list which are effective Jan. 1, 2018 . See our current list of prior authorization services here .

  • Applied Behavioral Analysis
  • Allergy Testing - RAST and ALCAT
  • Cardiac Event Monitors (Loop recorders and Mobile Outpatient Cardiac Telemetry)
  • Electorcardiographic event recorder - patient activated 
  • Continuous Glucose Monitors
  • Cystourethroscopy with mechanical dilation
  • Diabetes Online Intensive Program for Prevention
  • Genetic Testing
  • Left Ventricular Assist Device (LVAD) and Total Artificial Heart Implantation 
  • Monitored Anesthesia for Routine Endoscopic Procedures
  • Varicose Vein Procedures 
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

2018 Network updates

Servicing facility documentation

Authorization for ultrasound services no longer required

Oral appliance billing

Online referral and authorization guidelines

NCQA recommendations for breast cancer screenings

Medication stockpiling update

Preferred drug program authorizations

New codes added to our prior authorization list
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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
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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