Oregon |September/October 2018
2019 Moda Individual plans transitioning to EPO network

With open enrollment running from Nov. 1 to Dec. 15, we would like to share some important changes about our 2019 Moda Health’s Individual plans, which are available to Oregon Individual members who purchase health coverage directly from Moda and through the federal marketplace (healthcare.gov). These changes include:

  • Starting Jan. 1, 2019, all Oregon Individual plans including Beacon EPO, Affinity EPO and Cornerstone EPO will be connected to an Exclusive Provider Organization (EPO) network. Since Individual EPO plans do not have out-of-network benefits, it is important that you refer your patients to providers within the Individual plan and network that they are enrolled in.

Please review your patient’s Moda member ID card and check our provider directory, Find Care, to make sure 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 out-of-pocket costs for patients enrolled in these plans. 

All Individual EPO plans require that a member select a primary care provider (PCP) 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 Moda’s Individual plans and networks, please call 877-605-3229 or email us at medical@modahealth.com.
New online prior authorization platform

Moda Health has partnered with CoverMyMeds to process electronic prior authorization (ePA) requests for medications that are covered under a member’s pharmacy benefit.

CoverMyMeds is a free online platform that accepts requests from your office’s electronic health record system, or directly through the CoverMyMeds portal. Prescribers and staff can begin using CoverMyMeds to submit ePA requests that utilize Moda’s custom criteria and question sets for all Moda Commercial, EOCCO and Medicare Advantage members. Please note: You must select the form specific to the line of business when submitting an ePA for your patient.

CoverMyMeds’ PA process helps you make faster determinations and an automatic PA renewal setup that supports medication adherence with your patients.

New to CoverMyMeds?
To get started, visit covermymeds.com and create a free account.

Weekly webinar trainings are available here. CoverMyMeds is happy to schedule personalized webinars at a day and time that’s convenient for you. Just email help@covermymeds.com or chat live to request a demo.

We appreciate your support in assuring Moda members and your patients receive higher quality of care. If you have any questions, please call our Moda Pharmacy Customer Service team at 888-361-1610.
Provider-based billing (RPM061) changes

Under the Medicare provider-based billing model, when a patient sees a physician who works in an office building that is owned by the hospital, the hospital can charge the patient a facility fee for the use of the building where the patient was seen. 

Effective Jan. 1, 2019 , Moda Health will no longer allow split billing of provider-based clinic services when performed in a hospital outpatient setting. This includes clinics that are located in an on-campus outpatient hospital (POS 22) or in an off-campus outpatient hospital (POS 19), and who bill with the hospital’s Tax ID number.

Revenue codes 0510–0519 (clinic)

  • Clinic charges (revenue codes 0510–0519) are facility fee split billing of clinic-based services. This split billing is not allowed, and revenue codes 0510–0519 are not reimbursable; charges will deny to facility/provider write-off. Participating providers and facilities may not balance bill the patient.

Revenue codes 0760–0769 (specialty services/treatment room)

  • Treatment Room Revenue codes 0760–0769 may only be billed when the patient is registered through the hospital business office for outpatient services on the hospital campus for a specific procedure performed in a treatment room.

  • Evaluation and Management (E/M) codes (CPT 99201–99215, and HCPCS code G0463) should not be billed under revenue codes 0760–0769. These procedure codes are not reimbursable under these revenue codes; charges will deny to facility/provider write-off. Participating providers and facilities may not balance bill the patient.

  • Other separately reimbursable services provided in a hospital-owned provider based clinic also should not be billed under revenue codes 0760–0769. 

  • These services are to be billed on a CMS1500 claim form or electronic equivalent, using POS 11 Office.

We appreciate your efforts to reduce unexpected costs related to the care Moda Health members receive.

View Moda Health’s Clinic Services in Hospital Outpatient Setting Reimbursement Policy here . Or, s ee a complete list of Moda’s reimbursement policies on our Reimbursement Policy Manual page .
Retacrit selected as the preferred medication for ESA injections

As part of our commitment to provide members with high quality, affordable care, Moda Health has selected Retacrit (epoetin alfa-epbx) as the exclusively preferred short-acting Erythropoiesis-Stimulating Agent (ESA).

Beginning Jan. 1, 2019, all Moda fully insured groups, Individual members, and select ASO will be limited to receiving Retacrit, unless deemed medically inappropriate. If there is clinical documentation that Retacrit is ineffective, not tolerated or contraindicated, Epogen or Procrit may be administered with a prior authorization approval by Magellan Rx.

Members currently receiving ESA injections with a non-preferred product (Epogen or Procrit) may complete their current course of therapy as it applies to the existing authorization period.

Please note: Prior authorization for Retacrit is not required.

To learn more about our ESA medical necessity requirements, visit our medical necessity criteria page .

We appreciate your support in assuring our members receive quality care. If you have questions, please call our Customer Service team toll-free at 877-605-3229.
Prior authorization requirement changes

Effective Jan. 1, 2019, the prior authorization requirement for interferon beta-1a (Avonex) and dimethyl fumarate (Tecfidera) will be removed for Commercial members.
  • Ocrelizumab (Ocrevus):

  • Effective Oct. 1, 2018, ocrelizumab (Ocrevus) will no longer be included in the Site of Care (SOC) program.

  • As of Dec. 1, 2018, the requirement for an inadequate response, intolerance, or contraindication to natalizumab (Tysabri) prior to coverage of ocrelizumab (Ocrevus) will be removed.

  • Moda does not require the use of another medication before approval. 
VSP benefits for Medicare Advantage members

Moda Health has partnered with VSP (Vision Service Plan) to offer Moda Health Medicare Advantage members an enhanced routine vision and vision hardware benefit starting Jan. 1, 2019. We’d like to offer Moda’s participating Medicare Advantage providers the opportunity to join the VSP provider network.

Joining the VSP network ensures Medicare Advantage members receive the highest routine vision and routine hardware benefit available. The benefit will be available to members who seek routine vision and routine hardware from a VSP network doctor.

Participating Moda Medicare Advantage providers may join the VSP provider network by calling VSP at 800-615-1883.

Participating Moda Health Medicare Advantage providers should continue to send non-routine vision services to Moda. VSP only administers routine coverage within our Medicare Advantage plans.

Learn more about VSP’s Advantage plan online or by calling 800-615-1883
TruHearing benefits for Medicare Advantage members

Moda Health has partnered with TruHearing to offer Moda Health Medicare Advantage members enhanced benefits for routine hearing aid exams and hearing aids starting Jan. 1, 2019. We’d like to offer our participating Medicare Advantage providers the opportunity to join the TruHearing provider network.

Joining the TruHearing network ensures Moda Medicare Advantage members receive the highest hearing aid exam and hearing aid benefit available. The benefit will be available to members who seek routine hearing aid exams and hearing aids from a TruHearing network doctor.

Participating Moda Medicare Advantage providers may join the TruHearing provider network by calling TruHearing at 855-286-0550.

Participating Moda Health Medicare Advantage providers should continue to send non-routine hearing aid exam and hearing aid services to Moda. TruHearing only administers routine coverage within Moda’s Medicare Advantage plans. 

Learn more about TruHearing plans online or by calling 800-615-1883
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

2019 Moda Individual plans transitioning to EPO network

New online prior authorization platform

Provider-based billing (RPM061) changes

Retacrit selected as the preferred medication for ESA injections

Prior authorization requirement changes

VSP benefits for Medicare Advantage members

TruHearing benefits for Medicare Advantage members
Go digital today!

If you want to start exchanging information electronically with Moda, please contact the Moda Electronic Data Interchange team at edigroup@modahealth.com
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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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