Moda Health Medical Provider News Update
Fall 2015  |  Issue 14
Advanced Beneficiary Notice update

On May 5, 2014, the Centers for Medicare and Medicaid Services (CMS) released a bulletin noting that the use of the Advanced Beneficiary Notice (ABN) form for Medicare Advantage enrollees is prohibited.

Unlike members enrolled in the Fee-for-Service (Original) Medicare program, Medicare Advantage (MA) enrollees have the option to obtain a coverage decision prior to obtaining 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 either an approval or denial based on its review of the requested item or service.
  • If a member is seeking services covered under Original Medicare or the Medicare Advantage 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 that).
  • If 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. 
It's important to note that either the enrollee or the provider can request an organizational determination, but 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 obtain 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 then enter into a private fee arrangement for the denied services or items.

  • ABN forms are prohibited from use for MA enrollees.
  • The requirement to request an organizational determination applies to MA members regardless as to whether the service is statutorily non-covered by original Medicare or the service 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 (PA). Pre-service organizations are requested by the MA member or provider while PA requirements for certain items/services are set by the MA plan to verify the medical necessity of the item/service before they are performed or dispensed. 
To request a pre-service organization determination for MA members, please call 503-243-4496 (toll-free 800-258-2037) or fax 855-637-2666 today.
Commercial risk adjustment record review

Moda is currently conducting a clinical record review process for 2015 dates of service in ACA plans. This process is part of a commercial risk adjustment review related to the risk adjustment rules established as part of the Affordable Care Act (ACA) to stabilize risk for individual and small group plans inside and outside of the exchange marketplace. This process is not for payment review or audit, but rather will serve to ensure that Moda has the necessary documentation to comply with ACA requirements.

We have partnered with Enterprise Consulting Solutions (ECS) to assist us with this process, and we have designated them as an authorized representative in the matter of securing medical records, supported by a Business Associates Agreement. In the event that your office or clinic has provided services to one of the members in the sample, an ECS representative will be contacting you in the near future to provide details for the clinical records we must obtain. We're using these records to help gather diagnosis information to ensure a complete and accurate clinical background for our member.

Our goal 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, or other support to ensure that these requests can be completed in a timely manner. If you have questions about this process, please contact one of the following groups for assistance:

ECSprovider support:
Moda Health's Kim Otanic:

Thank you in advance for your cooperation, assistance and prompt attention to this review process. As part of our provider community, we appreciate your support in facilitating these ACA requirements to increase the access for individuals and small groups to quality medical health plans.
Reimbursement policy document specific to hospitals

Moda is developing a reimbursement policy document to address items and services not separately reimbursable to hospitals. It will include routine supplies and services, as well as room and board services. It will summarize a number of key topics we encounter in our hospital claim reviews, and outline the applicable guidelines and policies for these issues. This document will be completed and available to you on our website soon.

All policy statements follow CMS and industry standard guidelines for reimbursement of these services. As with all of our reimbursement policies, a bibliography-style list of references and sources will be included. 

The majority of the policy statements are not new; they've been applied on our hospital claim reviews over the past six years. Any new policy updates and items applied to all claim reviews will include an implementation date.
Hepatitis C treatment update

Moda is committed to providing our members with access to affordable and quality healthcare, including treatment of chronic Hepatitis C. Although new medications are more safe and effective than historic treatments, they come at a significant price, reaching $1,000 per pill or $100,000 for an average course of treatment.

Faced with this challenge, we've worked with manufacturers to provide effective treatment while maintaining a sustainable benefit. As a result, Harvoni and Sovaldi-containing drug regimens have been selected as the preferred medications to treat members who qualify for treatment of chronic Hepatitis C. Please note that all Hepatitis C treatments are specialty medications, which require authorization through Moda. We partner with Ardon Health for specialty medication management. With Ardon Health, ordering patient prescriptions is quick and easy. Simply fax an Ardon prescription enrollment form to 855-425-4096. Forms can be found at or by calling 855-425-4085.

As new medications to treat hepatitis C become available, we will evaluate the clinical data supporting these treatments and update our formularies as required. 
Shoo the flu!

Flu season is upon us. The Centers for Disease Control and Prevention (CDC) recommends annual flu vaccinations for all persons aged six months and older.

Moda is doing our part to help keep our local community and schools safe by covering routine immunizations for members of all ages at $0 copay (for most Moda plans) when going to an in-network professional provider or pharmacy. Encourage your patients to get a jump on the flu season by getting a free flu shot from any in-network provider. Learn more by visiting the CDC website
Get reimbursed by performing sports physicals during well-care visits

Take advantage of your scheduled sports physicals by conducting and billing for an adolescent well-care visit. Doing so will make it more convenient and less expensive for Moda members.
  • Prevent families from paying for annual sports physicals. We know the sports physical fee can be a barrier for families to participate in extracurricular activities, sometimes determining whether or not kids will play sports at all.
  • Make it easy for our teens. We know teenagers don't always love going to the doctor. They are healthy and happy and just want to have fun. A sports physical may be the only time a teenager engages with you, which is why you are crucial in securing their foundation for a healthy future.
What qualifies as a well-care visit?
A visit is qualified as well care if you perform the following:
  • Prepare a history that includes health and development, such as social and emotional well being, health behavior, academic history, physical development and mental health.
  • Provide a physical exam.
  • Do an assessment and create a plan that includes health education and anticipatory guidance, such as reproductive health, alcohol and tobacco avoidance, and violence and injury prevention.
EOCCO will reimburse you for performing sports physicals during an adolescent well-care visit. All you need to do is conduct a well-care visit and follow the billing/coding guidelines for these visits. Click on the Incentive Measure Reference Guide for billing and coding information. 
Medical necessity criteria update: 

For new and updated Medical Necessity Criteria, please check out our provider websiteChanges include:
  • Wheelchair criteria has been separated into three different criteria:
    • Wheelchairs manual
    • Wheelchairs power
    • Wheelchair accessories and options
  • Name changes for the following criteria are based on Medicare guidelines:
    • Insulin Pumps are now External Infusion Insulin Pumps
    • Ankle-Foot Orthotic (AFO)
    • Knee Orthotics (KAFO)
    • High Frequency Chest Wall Oscillation (HFCWO)
In This Issue
Join our email list
Visit our website and click on "Join our email list" in order to begin receiving quarterly newsletters, as well as occasional electronic communications.
Moda Health Contact Information
For claims review, adjustment requests and/or billing policies, please contact
Moda Health Medical Customer Service
at (888) 217-2363 or email
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

Moda Health | 503-228-6554 |
601 S.W. Second Avenue
Portland, OR 97204