Moda Health Medical Provider News Update
Spring 2015  |  Issue 12

March is Colorectal Cancer Awareness Month


As you know, the Center for Disease Control and Prevention (CDC) recommends that individuals age 50-75 get regularly screened for colorectal cancer. Screening tests help prevent colorectal cancer by detecting precancerous polyps for easy removal. Screening also allows the cancer to be caught early, when treatment is most effective. Testing guidelines include:

  • Colonoscopy (every 10 years)
  • Fecal occult blood test (FOBT) every year
  • Sigmoidoscopy (every 5 years)

Under the Affordable Care Act (ACA) all preventive screenings and services, including preventive colorectal cancer screenings, are covered at 100 percent with no patient financial responsibility.

Second to lung cancer, colorectal cancer is the most common cause of death from cancer in both men and women in the U.S. Early detection saves lives. Regular screenings help catch cancer early, when the disease is much easier and less expensive to treat. As you know, patients with precancerous polyps or even colorectal cancer don't always notice symptoms before the disease is identified. Testing early and regularly is crucial to saving lives.

Commercial Risk Adjustment Record Review


Moda Health is currently conducting a clinical record review process for 2014 in ACA plans.  This process is part of a Commercial Risk Adjustment Review related to the risk adjustment rules established by the ACA to stabilize risk for individual and small group plans inside and outside of the exchange marketplace. Please note that this process is not for payment review or audit. Instead, it will serve to ensure that we have the necessary documentation to comply with ACA requirements.

We have partnered with EMSI to assist us with this process. Through a Business Associates Agreement, we have designated them as an authorized representative in the matter of securing medical records. If your office or clinic has provided services to one of the members in the sample, an EMSI representative will contact you in the near future to provide the details for the clinical records we need to obtain. We use these records to help gather diagnosis information to ensure a complete and accurate clinical background for our members.


Our objective is to retrieve these records with as little disruption to your office as possible. We will work with you to access records remotely, provide copy assistance, and any other support to ensure that these requests can be completed in a timely manner. If you have questions, please contact the following:


Provider Relations Department

Kim Otanic


Thank you for your cooperation, assistance and prompt attention to this clinical record review process. We appreciate your support in helping us ensure better care for our members.

Billing changes for routine/screening lab tests

Proper payment of preventive services by Moda is dependent upon claim submission using diagnosis and procedure codes that identify the services as preventive. Most preventive/routine diagnosis codes are ICD-9 "V-codes". However, many "V-codes" are not routine, such as V58.1 (encounter for chemotherapy). Services like this are medical in nature and paid under the medical benefits of the plan, with deductible and coinsurance (member cost-sharing).

New CPT codes covered for screening


In addition to the mandated ACA preventive benefits, Moda does cover a small list of additional lab CPT codes at the medical lab benefit level (not necessarily no member cost-share) even when billed with a routine, preventive, or screening diagnosis code (aka "category 2 preventive coverage"). For a complete list, see our Preventive Services Reimbursement Policy. The following CPT codes were added in September 2014:

  • 80050 (General health panel)
  • 80053 (Comprehensive metabolic panel)
  • 80061 (Lipid panel)
  • 83036 (Hemoglobin; glycosylated (A1C))
  • 84443 (Thyroid stimulating hormone (TSH))
  • 85025 (Blood count; complete (CBC), automated)

All other lab test CPT codes are not covered when billed with routine/preventive/screening diagnosis codes. We recognize that you may perform certain tests during your routine and preventive exams that are not included in the government guidelines and/or our list of additionally covered routine tests. You can still order those tests, but please understand that in the absence of a diagnosis code of injury or illness they will not be covered under the member's health plan.  


New changes for financial responsibility of non-covered screening tests:


Effective for claims dated 2/1/15 and after, any non-covered routine lab CPT codes billed with modifier GA or GX will be denied to member responsibility. Modifiers GA and GX indicate you have obtained from the member a signed waiver of liability form and can provide it to us in case of a member appeal. If a non-covered routine lab CPT code is billed without modifier GA or GX, it will be denied to provider write-off.


Our Reimbursement Policy for Preventive Services versus Diagnostic and/or Medical Services (policy  # RPM037) has been updated to reflect this information and is available online here.

It's HEDIS Medical Record Review season!



We are excited to announce our kickoff of the new HEDIS 2015 medical record review season! Each year, we review a small sample of charts to evaluate quality measures. This year we're working on nine quality measures (see below). We will be working closely with our partners HealthPort and KDJ Consultants to collect and review charts.  HealthPort and/or KDJ Consultants will contact you in March if any of your Moda-covered patients have been selected for chart review.  

HEDIS 2015 Measures

  1.       Adult Body Index
  2.       Cervical Cancer Screening
  3.       Childhood immunizations
  4.       Colorectal Cancer Screening
  5.       Comprehensive Diabetes Care
  6.       Controlling High Blood Pressure
  7.       Human Papillomavirus Vaccine
  8.       Prenatal and Postpartum Care
  9.       Weight Assessment and Counseling for children

Our goal is to make this process as simple and smooth as possible. If you have any comments about ways we can improve or are interested in learning more about the HEDIS process and results from your review, we would love to hear from you! Please email your comments and contact information to We will be happy to provide details on the quality measures we evaluated at your practice. 


We're dedicated to providing the highest quality care to our members and are grateful to have so many providers to partner with to continuously raise the bar in our HEDIS quality metrics!


To learn more about HEDIS measures and how it impacts your practice, click on one of the following documents:


HEDIS Overview



Medical Management Utilization Review updates

Medical criteria updates:

  • Therapeutic Drug Monitoring Medical Necessity Criteria for urine drug testing has new codes for testing and coverage. Please review the new criteria online here.
  • Investigational Services and Supplies Medical Necessity Criteria has updated wording that considers the grouping of procedures or tests for evidenced-based support. The requested procedures or tests must be appropriate for the diagnosis.

Reference pricing programs:

  • Several groups have contracts with facilities for hip and knee replacement, bariatric procedures and oral appliances. Please verify with Moda Customer Service if your member's plan is subject to the reference price and that the requested facility is participating in reference pricing.
  • Members should be informed if the facility is not included in the reference price program as this may result in additional out-of-pocket expenses.

MagellanRx (formerly ICORE) Specialty Drug Program:


New drugs have been added to the ICORE specialty drug review list as of January 1, 2015. Criteria for the new drugs are posted online here.

New requirements for CPT Code 99070 and billing of supplies

  • CPT code 99070 will no longer be considered a valid procedure code for submitting charges for supplies and materials.
  • Charges submitted under CPT code 99070 will be denied to provider write-off with an explanation code mapped to Claim Adjustment Reason Code 189. (Not otherwise classified or "unlisted" procedure code [CPT/HCPCS] was billed when there is a specific procedure code for this procedure/service.)
  • When an unlisted HCPCS code is submitted, the claim must have a description of the item supplied in the supplemental information section of the paper or online claim. For example, a naturopathic visit may result in a claim such as:

Line #
Code Description
Supplemental Description for Unlisted Codes
Established patient evaluation and management visit
Prescription drug, oral, nonchemotherapeutic, NOS
Crucera - SGS 180 caps
Prescription drug, oral, nonchemotherapeutic, NOS
Bio- Gest 120 caps


Supplies are included in the RVU for surgical and medical CPT codes


Beginning in 2002, the CMS included an allowance for medical and surgical supplies into the practice expense portion of the RVU for each procedure code. These items are not eligible to be reported separately. Payment is included in the reimbursement for the primary service procedure code.


Any supplies or materials that are billed separately need to be 1) not already included in the RVU for the primary services billed, and 2) clearly identified on the claim by specific HCPCS codes or description for all unlisted HCPCS codes billed.


Click here to view a copy of the updated Reimbursement Policy for medical, surgical, and routine supplies, which addresses these requirements.

We'd love to hear from you!


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Reimbursement policy and medical necessity criteria updates


To keep you updated on all of our policies and medical necessity criteria, Moda Health posts an updated listing of medical necessity criteria information in our Provider resources website. Additional resources include:


Moda Health Reimbursement Policy updates


New Medicare updates


For more information, visit us online or call Customer Service at 503-243-3962.
Go digital today!


If you would like to start exchanging information electronically with Moda Health, please contact the Moda Health Electronic Data Interchange team at


If you have questions regarding your contract, please contact Medical Professional Relations at 877-664-4762.


For all other questions, please contact Medical Customer Service at 888-788-9821.

In This Issue
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