Moda Health Medical Provider News Update
Summer 2015  |  Issue 13

June is Men's Health Month


Like all populations, preventive care is crucial for adult men. Studies show they are more likely to put off regular check-ups, less likely than women to visit their doctor and often neglect their cholesterol levels. Along with ignoring preventive care, men have a greater likelihood of complications related to cardiac disease, diabetes, and pneumonia that can result in long inpatient stays.


Because of this, the United States Preventive Services Task Force recommends the following screenings for adult men:

  • Alcohol misuse screening & behavioral counseling interventions
  • Colorectal cancer screening (aged 50-75)
  • Depression screening
  • Diabetes Mellitus (Type 2) screening
  • Hypertension
  • Lipid disorders (aged 20-35)
  • Sexually transmitted illnesses (including HIV)
  • Tobacco use counseling

As you know, there are health issues that solely affect men like prostate cancer. Many of the major health issues that men face including colon cancer and heart disease can be prevented and treated when detected early. As your health partner, we thank you for the excellent care you provide Moda members.


To learn more about preventive care for adult men, check out the following websites:

Proper chlamydia screening codes


Chlamydia is a serious public health issue across the U.S., but specifically in the state of Oregon. For women, the disease often is asymptomatic. Left untreated, chlamydia can cause pelvic inflammatory disease, and even infertility. The Oregon Health Authority and the Centers for Disease Control & Prevention recommend annual screening all sexually active women under the age of 25. This screening is billable to Moda, and under the Affordable Care Act, when it is billed with a preventive diagnosis, is covered with no cost to the patient.


We would like to acknowledge that some providers have been using and billing CPT 87801 or CPT 87800 for a combined chlamydia and gonorrhea screening. While this is an appropriate code, we understand it is denying back to provider write-off . We are seeking your support to bill us for chlamydia screening with one of these other approved codes (87270, 87320, 87110, 97490 and 97492). There is also the option to screen via urine sample (CPT 87491).


These codes are reimbursable per your contracts as participating providers. They also fall under the Healthcare Effectiveness Data Information Set (HEDIS) specifications for Moda's quality tracking purposes.

New Moda credentialing tool for providers

To answers general questions about our credentialing process, we've created a new Credentialing resource website. These pages include requirements for credentialing with Moda, forms and contact information, and additional data we need to start this process.

If you have any questions, please contact our Credentialing department at or


HEDIS Medical Record Reviews are complete!


Thanks to you, we've completed our HEDIS Medical Record Review process for 2015! We truly could not have done it without you. Each year we try to work out the kinks of this process to reduce the burden on you and your fantastic support staff. This year, we're able to remotely access charts to over 10 healthcare systems. Remote accessibility provided many benefits for both parties, including decreased onsite staff workload, no onsite interruptions, and eco-friendly (no copying, faxing and/or mailing).


If you have any comments about how we can improve or just want to learn more about the HEDIS process, we'd love to hear from you. Please email us at We are committed to providing the highest quality care to our members.


We appreciate your flexibility and patience in accommodating our request to improve our quality measures. We are grateful to have so many providers to partner with and help us raise the bar in our HEDIS quality metrics.

ICD-10 update


For the past few months, Moda has been coordinating end-to-end ICD-10 testing with our clearinghouses. Our goal for the ICD-10 testing process is to provide thorough feedback on test claims to ensure that the newly coded test claims provide the same or similar benefits and payments as they did with ICD-9 codes that were previously submitted in production. Our claims team has meticulously reviewed hundreds of these test claims and provided detailed comparisons to our trading partners on how closely the ICD-10 codes match our expectations. We also generate the PDRs or electronic remittances for the test claims received, providing an additional look on how the transition to ICD-10 will appear to our providers.


As part of the ICD-10 testing process, we will be undertaking volume testing with some of our trading partners. This will include processing a larger batch of ICD-10 test claims to simulate a normal day's volume to provide high-level feedback on what a day in the life will look like once the transition to ICD-10 is complete.


With July 31, 2015 being the end of our ICD-10 testing window, we are committed to working with our trading partners to complete this testing and to provide the quality results that we strive for.

A resource for Oregon's credentialing organizations

With the passage of Senate Bill 604 in the 2013 regular Legislative session, the Oregon Health Authority is required to establish a program and database for the purpose of giving credentialing organizations access to information necessary to credential all healthcare practitioners in the state. Learn more today at the

Oregon Common Credentialing Program website.

ICORE now part of Magellan Rx Management


ICORE Healthcare is now part of the Magellan Rx Management family. Through this restructuring, we're proud to introduce Magellan Rx Specialty, the specialty pharmacy division of Magellan Rx Management. This simple change is designed to align their names and bring together our pharmacy solutions while still delivering the quality service and personalized care you've come to expect. 

Over the next several months, you'll see a few changes:

  • ICORE's medical pharmacy business will operate under the Magellan Rx Management name
  • The ICORE website will retire and Magellan Rx will re-launch

Your executive leadership, sales and account executive will not change. They will continue to work closely with you to ensure all your materials and websites are updated, as needed.

Help us keep your practice details up-to-date


To ensure 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 Centers for Medicare and Medicaid requirement for having the most up-to-date information about your practice or facility available to our members, please email our Provider Relations team at when any of the following changes occur, and include the effective date:

  • a new street address, phone number or office hours
  • when you are accepting new patients status for all contracted Moda lines of business; or
  • when any changes occur that affect the availability of providers in your practice


This will help ensure our members can locate providers that are available and best suit their needs.

 New National Drug Codes policy


New requirements are being implemented for medical plan drug billing. Starting September 1, 2015, National Drug Codes (NDCs) must be fully documented on all drug claims. This means complete NDC information will be required on all professionally administered drug claims billed to Moda for the Oregon Health Plan, Medicare, and commercial members. This requirement will apply to claims billed in a professional office, home or outpatient setting submitted electronically and/or on paper. NDC details will not be required on inpatient claims. See the following example of a correct NDC code:

In addition to the CPT/HCPCS code, claims must include the NDC code and the specific unit of measure to the metric decimal for the drug billed. The unit of measure must be noted to the metric decimal. If any of this information is missing or invalid, the claim will be denied to provider liability, and must be corrected for reimbursement.


Click here to learn more about National Drug Code requirements.

Claim edits policy


In partnership with Magellan Rx, we are very excited to announce the expansion of its claim check program for injectable and/or infusion drugs. Beginning September 1, 2015, we will enhance this program to help monitor and promote appropriate use, safety, and cost effectiveness of medications prescribed to our members. We will do this by reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes.


The program will be limited to claims reviewed and to medications injected and/or infused in a professional office, home or outpatient setting. Please take a moment to check out the initial list of injectable and/or infusion medications that will be included in the program. As we gain better insight into utilization patterns, we will expand this list to include specialty and injectable medications.

2015 prescription benefit updates

Moda's prescription program is a pharmacy benefit that offers 
members a choice of safe and effective medication treatments that also saves them money on prescription drugs. Periodically,medication coverage changes will occur. This allows us to maintaincomprehensive benefit and provide you with an open formulary and choice, which supports the program's ongoing stability.


Our prescription program uses a tiered copay/coinsurance system. As a provider, your patients can choose between the value,select, preferred or brand tier medications.What your patients pay for a drug depends on their plan.  


Please review the following expected Commercial July 2015 Formulary updates. Recent quarterly updates have also been included as a reference. Please note that this information could change and does no represent every potential update to your patients' benefits.Please have members refer to their Member Handbook for specific tier and coverage information. For questions, call our Pharmacy Customer Service team toll-free at 888-361-1610.

Moda joins fight against preventable death


The Oregon Coalition for Responsible Use of Meds is a statewide coalition that works to prevent overdose, misuse and abuse of amphetamines and opioids among Oregonians. Over the past decade, the coalition has seen a dramatic increase in opioid and heroin related deaths in Oregon. As a result, Moda has joined the nationwide fight against preventable death by advocating for broader availability of naloxone, an inexpensive drug that when administered in situations of opioid and heroin related overdoses can reverse the effects of respiratory depression to prevent death.


To promote programs that train the general public how to administer naloxone, Moda has added naloxone vials to our pharmacy benefits. We hope this will encourage more members to obtain training in the use of naloxone and promote a safer and healthier community. Learn more about the Naloxone training here.

Advanced Premium Tax Credit added to EBT

With the individual health exchange, quality providers like you now have more access to patient benefit information. One benefit that the exchange provides to help individuals find custom plans that fit their health goals and budgets is the Advanced Premium Tax Credit (APTC).

APTC is federal subsidy used to assist qualifying individuals and families obtain more affordable health coverage through reduced monthly premiums. It gives individual members who are delinquent in paying their monthly premium a three-month grace period.

To help you efficiently identify the benefits of Moda's diverse member population, the Enterprise Benefit Tracker online tool provides APTC details when viewing member benefits. When a member is delinquent on their monthly payment, EBT displays the following data:

  • APTC member identifier
  • ATPC premium paid through date
  • 30-day grace period (see sample)
  • Extended 60-day grace period (see sample)
During the first month of a member's grace period, which starts when they've paid their first month's premium, claims will be considered at regular plan benefits and compliant with APTC. Once the member enters their extended 60-day grace period, however, claims will be pending until the full premium is received.

Medical Necessity Criteria updates


For new and updated Medical Necessity Criteria, please check out our provider website. The following updates are effective Aug. 1, 2015:
  • New infusion drug criteria:
    • Nivolumab (Opdivo)
    • Pembrolizumab (Keytruda)
    • Ramucirumab (Cyramza)
    • Vedolizumab ( Entyvio)
  • Intraoperative Neurophysiologic Monitoring

We've also changed the names and made updates to the following procedures:

  • Mammography Adjunct Technology (formerly Computer Aided Detection) now includes criteria decision for the digital breast tomosynthesis procedure.
Lung Cancer Screening (formerly Low Dose CT for Lung Cancer Screening) now includes the current recommendations for low dose CT and other lung cancer screening procedures. 

Help lower your patients' out-of-pocket costs


To help your patients avoid higher out-of-pocket costs, make sure that all referrals and downstream services such as lab and imaging services are performed by an in-network provider.


We know that additions of the Rose City, Community Care, Synergy and Summit networks can pose a challenge to identifying practices and ancillary services in these networks. However, using the Find Care provider directory makes it easy for you to locate the specific provider and services you are looking for. 

Changes to the Joint Reference Price Program


Effective March 1, 2015, the Joint Reference Price Program (for hip/knee replacements) was removed from all Summit and Synergy products (Plans A-H). This has been approved by Moda Health and OEBB to make this change mid-plan year. This change helps eliminate the overlap of incentives for the risk models and the reference pricing. Summit and Synergy handbooks have been updated by Contracts (Joint Reference Price language removed) and will be posted online.

Please note that this change is only for Summit and Synergy plan options. The Joint Reference Price Program will remain in place on all statewide plans.

Moda planning provider workshops


The Moda Health Provider Relations team is gearing up for our 2015 provider workshops! The workshops will be held at the following locations:


>    Medford

>    Eugene

>    Corvallis

>    Salem

>    Bend

>    Pendleton

>    Portland


Invitations will be sent in the coming months. Space is limited, so please RSVP as soon as possible! You can also check our Workshops website for updates. We look forward to seeing you there.

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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Portland, OR 97204