Oregon |November/December 2018
Individual plans switching to EPO

We want to remind you that beginning Jan. 1, 2019 , all Moda Health Oregon Individual plans including Beacon EPO, Affinity EPO, and Cornerstone EPO, will be connected to an Exclusive Provider Organization (EPO) network. Individual EPO plans do not have out-of-network benefits, so it is important that your patients are referred to providers within the Individual plan and network that the patient is enrolled in.

Please review your patient’s Moda member ID card (see example, below), and check our provider directory, Find Care, to ensure care is referred to other in-network Beacon, Affinity, or Cornerstone providers. Services provided to Moda Individual members by out-of-network providers will result in higher costs for patients enrolled in these plans.

All Individual EPO plans require that a member select a Primary Care Provider within the network they are enrolled in. A member’s PCP works closely with the rest of their care team (other providers, specialists, etc.) to help them achieve better health and wellness.
To learn more about our Individual plans and networks, call 877-605-3229 or email us at medical@modahealth.com.
2019 code updates for applied behavioral analysis

Moda Health recently communicated to Applied Behavioral Analysis providers about the American Medical Association's announcement that Category III CPT codes for applied behavioral analysis (ABA) will be replaced by eight permanent Category I and two modified temporary Category III CPT codes.
Effective Jan. 1, 2019, Moda Health will require ABA therapy codes 0359T-0374T be billed with the updated code listed below. Services billed after Jan. 1, 2019, with the 2014 ABA therapy code set will be denied as provider write-off.
If you are currently a Moda Health contracted ABA provider and have questions related to your current agreement with Moda Health, please email behavioralhealthcontracts@modahealth.com.
2019 code updates for psychological and neurological testing

Moda Health recently communicated to Behavioral Health providers about the American Medical Association's announcement that psychological and neurological testing CPT codes 96101-96103 and 96118-96119 will be deleted. These codes will replaced by 20 CPT codes that more accurately describe the amount of time needed to provide the service.
Starting Jan. 1, 2019 , Moda Health will require psychological (96101-96103) and neurological (96119-96120) testing codes be billed with the appropriate code listed below. Services billed with the 2018 Psychological and Neurological testing codes will be denied as provider write-off.
If you are currently a Moda Health contracted Behavioral Health  provider and have questions related to your agreement with Moda Health, please email behavioralhealthcontracts@modahealth.com.
Pre-service organization determination for Medicare Advantage members

The Centers for Medicare and Medicaid Services (CMS) prohibits the use of the Advanced Beneficiary Notice (ABN) form for Medicare Advantage enrollees.
Unlike members enrolled in the Fee-for-Service (Original) Medicare program, Medicare Advantage (MA) enrollees have the option to get a coverage decision before receiving the item or service. This coverage review is a request for a pre-service organization determination. The MA plan will review the request and issue an approval or denial based on its review if:

  • A member is seeking services covered under Original Medicare or the MA plan, a pre-service organization determination is not required (keeping in mind that this does not negate the pre-authorization requirement if a service requires it).
  • A member is seeking services that are either statutorily non-covered services under Original Medicare or non-covered by the MA plan, a pre-service organization determination is required to protect the member. 

Please note that either the enrollee or the provider can request an organizational determination. However, Moda encourages our contracted providers to use our current structure for requesting a pre-service organization determination on the enrollee's behalf.
If a service is denied, the MA member will be better informed to choose if they wish to appeal the denial or would still like to get the service at their own expense. If a member chooses to proceed with the service (after exhausting the appeals process or deciding not to pursue an appeal), the member and provider can enter into a private fee arrangement for the denied services or items.

  • The requirement to request an organizational determination applies to MA members no matter if the service is statutorily non-covered by original Medicare or is non-covered by the MA plan.
  • If a contracted provider furnishes such non-covered services without the organization determination, the non-covered charges would be subject to provider write-off. 
  • A pre-service organizational determination is NOT the same process as the MA plan requiring a prior authorization. Pre-service organizations are requested by the MA member or provider while PA requirements for certain items or services are set by the MA plan to verify the medical necessity before they are performed or dispensed. 

To request a pre-service organization determination for MA members, please call 800-258-2037 or fax 855-637-2666.
2019 policies for Medicare Part D opioid overutilization

CMS understands the magnitude of the nation’s opioid epidemic and its impact on our communities. Opioid medications are effective at treating certain types of pain, but have serious risks such as increasing tolerance, addiction, overdose and death. Given the scope of this crisis, in June 2018 CMS published a roadmap detailing a three-pronged approach to combating the opioid epidemic. It includes:

  1. Prevention of new cases of opioid use disorder (OUD)
  2. Treatment of patients who have already become dependent on or addicted to opioids
  3. Utilization of data from across the country to better target prevention and treatment activities.

Starting in January 2019, Medicare Part D plans will employ the following new safety alerts at the pharmacy:

  • Opioid prescriptions will be monitored for safe dosage levels. If one or more opioid prescription is above a safe dosage limit, the prescription will be stopped at the pharmacy for review by the prescriber to make sure that the prescription is medically necessary and appropriate.
  • Opioid prescriptions that are taken together with benzodiazepine prescriptions will be stopped at the pharmacy for review by the prescriber to make sure that the prescriptions are medically necessary and appropriate.
  • Members who have not had a recent prescription for opioids will be limited to no more than a seven-day supply for their first opioid prescription for the treatment of acute pain.
  • Prescriptions for Long-Acting Opioids that are taken at the same time will be stopped at the pharmacy for review by the prescriber to make sure that the prescriptions are medically necessary and appropriate. 

To learn more, including guides for prescribers, please visit CMS’s Improving Drug Utilization Review Controls web page.
eviCore online resources

eviCore Healthcare and Moda Health understand that requesting prior authorization for services can be difficult to understand. To help you save time, eviCore’s suite of online resources can help ensure prior authorizations are accurate and completed in a timely manner. Materials include:

  • Clinical guidelines
  • Quick reference tools with contact information and web portal directions by solution (radiology, cardiology, musculoskeletal)
  • Online forms that can be separated by solution
eviCore also offers webinars on a variety of topics to help you understand the prior authorization pathway. These sessions provide overviews for requesting prior authorization and radiology, cardiology and musculoskeletal programs.
Follow these steps to see a complete list of upcoming webinars:

  • Visit the eviCore website.
  • Click on the “Webex Training” link on the left side page.
  • Click the "Upcoming" Tab. Choose "eviCore Web Portal Training."
  • Click "Register" next to the session you wish to attend.
  • Enter the registration information.
After you have registered for the conference, you will receive an email containing the phone number and meeting number, conference password, and a link to the web portion of the conference. Please keep the registration email so you will have the link to the web conference and the call-in number for your session.
If you are unable to participate in one of the scheduled sessions or have questions about the eviCore web portal, email the Web Support team at portal.support@evicore.com or call 800-646-0418. Please note that sessions are hosted each month, and new training schedules will be published, when available.

To learn more about eviCore’s online resources, visit eviCore’s provider resources page or email clientservices@evicore.com .
Injectable medication expansion

Effective March 1, 2019 , Ilaris (canakinumab) will be added to the  prior authorization list   of medications that are currently in the Magellan Rx program. Magellan Rx will review your 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
Learn more about the i njectable medication program and view the current medication list   here .
Urgent pharmacy prior authorization reviews

Moda Health classifies prior authorization requests as “urgent” in instances where the wait for the standard review timeframe could seriously jeopardize the life, health, or ability of the patient to regain maximum function.

Prioritization of such requests allows the Moda Health prior authorization review team to appropriately triage and ensure urgent cases are completed in a timely manner, and those cases for which a standard turnaround time would suffice, are not delaying the review of an urgent case.

For non-urgent pharmacy cases, the standard turnaround time takes on average up to 3 business days.

The Moda Health prior authorization team appreciates provider efforts in ensuring appropriate use of these dedicated resources.

For more information on requesting prior authorization from Moda Health, please visit our Pharmacy Utilization management website.
Prior authorization requirement changes

The following services will been added to our prior authorization list. Please s ee our current list of prior authorization services  here .

Brineura (cerliponase) Effective Jan. 1, 2019 , Brineura (cerliponase) will require prior authorization.

A complete list of services that require prior authorization, as well as contact information specific to the service, can be found on our referral and authorization guidelines website .
Medical necessity criteria updates

Effective Oct. 1, 2018
Effective Nov. 1, 2018

Effective Jan. 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

Individual plans switching to EPO

2019 code updates for Applied Behavioral Analysis

2019 code updates for psychological and neurological testing

Pre-service organization determination for Medicare Advantage members

2019 policies for Medicare
Part D opioid overutilization

eviCore online resources

Injectable medication expansion

Urgent pharmacy prior authorization requests

Prior authorization requirement changes

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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