Oregon  |  Winter 2015
Timing of hospice care
Discussing end-of-life needs is a challenging conversation to have with a patient and their loved ones. We are here to support you as you care for our members during this emotional and fearful time in their lives. National organizations such as the National Hospice & Palliative Care Organization (NHPCO) and leading research experts recommend having the end-of-life talk sooner rather than later. With a massive 634 percent increase (data from NHPCO) in patients requiring complete end-of-life care in the U.S. between 1990 and 2013, research shows that if a provider waits longer to refer a patient to hospice, the family believes the quality of care decreases and feels lower satisfaction overall with the palliative care process.

Best practices 
While the disease states and volume of population have shifted over time, the difficulty of end-of-life discussions remains the same. Here is some recommended protocol for discussing goals of care:
  • Create the right setting
    • Privacy
    • The right people present
  • Identify what the patient and their loved ones already know
  • Learn what they are expecting or hoping for
  • Suggest realistic goals
  • Respond empathetically
  • Make a plan and follow up
  • Review and revise the plan periodically, as appropriate
This is a challenging topic to broach with patients and their loved ones. There are helpful, clinically founded resources available for you and your team to navigate this discussion:

Complete your required Medicare compliance attestation by Dec. 22, 2015
The Centers for Medicare & Medicaid Services (CMS) requires any Moda Health first tier, downstream or related entity (FDR) such as a provider organization to complete certain compliance program requirements for Moda Health.
These include: 
General compliance and FWA training Code of conduct/compliance policies 
Exclusion list screenings Ensure reporting mechanisms for potential FWA and compliance issues 
Offshore PHI operation reporting Downstream entity oversight 
Please submit your attestation by Dec. 22, 2015, through one of the following channels:
Fax:       503-243-3964
Mail:     Moda Health/Provider Relations
               601 SW Second Ave., T-8
               Portland, OR 97204-3156
We're here to help! If you have questions about the Medicare attestation document, please contact our Moda Health Provider Relations team at providerrelations@modahealth.com.
Injectable medication program expansion
Are you aware that Moda Health has partnered with Magellan Rx Management (Magellan Rx) to assist you in medical pharmacy management through the provider-administered injectable drug program? To ensure our members receive quality, affordable care, we will implement updates to the review and approval processes of certain injectable medications.
Effective Jan. 1, 2016, 21 new medications will be added to the prior authorization list of medications 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
To view a complete list of injectable medications, visit modahealth.com/medical/injectables/.
Completing prior authorization requests through Magellan Rx will help expedite claims processing and doesn't require you to submit medical records. If you don't obtain a prior authorization, your claims may be delayed or denied until we receive the information needed to establish medical necessity. 
To learn more about our injectable drug program, please check out our updated Injectable Drug Program FAQ. We encourage you to sign up for one of the following training webinars (conducted by Magellan Rx) to acquaint yourself and your staff with the procedures that go into effect Jan. 1, 2016. 
  • Tuesday, Dec. 15, 2015, 8 - 9 a.m. PT
  • Wednesday, Dec. 16, 2015, 8 - 9 a.m. PT
To register for one of the webinars, please email the following information to injectablesolutions@magellanhealth.com. Once completed, you'll receive an email confirmation that will instruct you and your staff on how to access the webinar.
  • Webinar date
  • Physician or practice site name
  • TIN
  • Practice site address
  • Email and phone
  • Number of participants, specify if they are clinical or administrative
Why should your patients get vaccinated?
According to the Centers for Disease Control and Prevention (CDC), roughly 14 million people become affected with the human papillomavirus (HPV) each year, and about 26,000 cases of cancer are related to HPV. The HPV vaccine can help protect your patients from cancers caused by HPV, including:
  • Cervical, vaginal and vulvar cancers
  • Penile cancer
  • Anal cancer, oropharynx cancer and genital warts
The Advisory Committee on Immunization Practices recommends treatment for the following:
  • Preteen boys and girls age 11 or 12
  • Women between 13 and 26, or men between 13 and 21 who have not started or did not finish their HPV series
  • Young men ages 13 to 26 who have sex with other men or who have weakened immune systems 
Who is approved for vaccination per the Food and Drug Administration?

HPV types
Recommended for females
Recommended for males
Quadrivent HPV (HPV4, Gardasil)
6, 11, 16 & 18
9-26 years
9-26 years
Bivalent HPV
(HPV2, Cervarix™)
16 & 18Yes
9-25 years

The efficacy and safety of the vaccine has been demonstrated in clinical trials, per the Centers for Disease Control and Prevention (CDC). Currently, more than 95 percent of women who have not been previously infected are protected against cervical cancers by HPV 16 or 18. The vaccine is also 100 percent effective in preventing vulvar and vaginal pre-cancers and genital warts in women caused by the vaccine types. In males, HPV4 demonstrated 90 percent vaccine efficacy in preventing genital warts and 75 percent vaccine efficacy in preventing anal and pre-cancers caused by the vaccine types.
Despite the inherent risks, HPV vaccination rates currently remain low. Per the CDC, only 33 percent of teenage girls ages 13 - 17 received three doses of HPV vaccine in 2012. Doctor recommendations remain one of the most successful methods of influencing patients to get vaccinated. At Moda, we're 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 received from an in-network professional provider or pharmacy. Encourage your patients to get vaccinated today!
Free continuing education credits and tips about how to start the conversation with your patients are available through CARDEA. To find out more or register, go to cardeaservices.org/resourcecenter/you-are-the-key-to-hpv-cancer-prevention.
New CMS provider directory requirements
To ensure that we provide high-quality service to our members, Moda provides an online "Find a Provider" search tool. This tool helps members connect with our extensive network of contracted providers. As a contracted provider, we need your help to guarantee members have the most up-to-date information about you and your practice or facility. Additionally, the Centers for Medicare & Medicaid Services (CMS) requires that up-to-date provider information is available to Medicare Advantage and Part D (prescription drug) members at all times.
Please notify us if a change occurs to any of the following: (1) street address, (2) phone number, (3) office hours, (4) status of accepting new patients for all contracted Moda lines of business, or (5) any other changes that affect the availability of providers in your practice. This will ensure that our members can locate providers who are available and best suit their needs.
If you or your practice/facility needs to update any of your information, please contact providerupdates@modahealth.com and provide the current information.
Ardon specialty pharmacy is here to help
As a medical provider, your time is valuable. You spend most of your day caring for patients. That doesn't leave much time for ordering prescriptions and making sure patients get their medications.

Ardon Health is here to help patients on their health journey - and to assist you throughout the process of referring and treating your patients. As your Northwest specialty pharmacy partner, Ardon Health can handle your patients' medication needs so you can focus on doing what you love - providing great patient care. 

How Ardon can save you time
Ardon offers fast and easy prescription services for your patients. Just send them a prescription and they will do the rest, including:
  • Check your patient's prescription benefits
  • Coordinate prior authorizations, when needed
  • Review copay assistance options
  • Review prescription and patient information
  • Contact your patient to enroll them with Ardon
  • Schedule medication delivery
  • Connect your patient with Ardon's pharmacist
  • Screen medication during dispensing
  • Refill planning and coordination
In addition, Ardon's clinical team monitors your patients and will contact your office if there is a concern (such as side effects, drug interactions, adherence issues or signs of disease progression). Ardon's pharmacists are available 24/7 every day of the year to assist patients. 

Not sure which specialty pharmacy your patient can use?
No problem. When you send Ardon a prescription, they'll investigate your patient's benefits. If your patient is not able to use Ardon Health, they will transfer the prescription to the appropriate pharmacy.

Have questions about what financial assistance is available to your patients? 
Call Ardon and they will let you know. Connecting patients with financial and copay assistance programs is routine for them. By easing the financial burden of special medications, Ardon makes it easier for patients to follow their treatment plan.

Call Ardon toll-free at 855-425-4085 or email info@ardonhealth.com. TTY users, call 711. Ardon can also be found online at ardonhealth.com
Medical necessity criteria updates
We've recently made a number of updates to our medical necessity criteria. You can find the following chances online at modahealth.com/medical/medical_criteria.shtml.
New criteria:
  • Lemtrada (alemtuzumab)
  • Non-invasive testing for liver fibrosis 
Changes to current criteria (formerly used MCG™):
  • Surgical treatment for achalasia
  • Sinus surgery
  • Non-invasive, cell-free fetal DNA prenatal testing (archived - will use MCG)
  • Hyaluronic acid (viscosupplementation)
  • Stab phlebectomy-varicose vein therapy 
Criteria currently being reviewed for revisions:
  • Genetic testing
  • Intervertebral disc prosthesis
A new prior authorization list will be posted on the Moda website that will be effective March 1st, 2016 with a new look and improved access to criteria and important prior authorization information.

Effective Dec. 1, 2015, the following services will no longer require prior authorization:
  • Esophogastroduodenosocopy (EGD)
  • Home health and home infusion (some medications still require prior authorization)
  • Outpatient hospice care
  • Home sleep studies (one night, ages 18 and older)
  • Chiropractic services for Medicare Advantage members
Benefit coverage for self-administered medications
Beginning Jan. 1, 2016, the self-administered medications listed  here will no longer be a covered medical benefit when supplied in a professional office or outpatient facility. These medications will be covered according to the member's pharmacy benefit. Many self-administered medications are subject to Moda's enhanced specialty pharmacy program, which is serviced exclusively by Ardon Health. Ardon provides concierge service for providers and will ensure that there's no disruption in care for patients. 

Self-administered medications are prescription medications labeled by the FDA for self-administration. They can be safely administered by the member or the member's caregiver outside of a medically supervised setting (e.g., outpatient hospital, physician office or infusion center) and do not require administration by a licensed medical provider.

If self-administered medications are billed through the medical benefit on Jan. 1, 2016 or after, the charges may be denied as non-covered. This can be identified on the Provider Disbursement Register (PDR) with the explanation that "self-administered medications are excluded when supplied directly by a clinician's office, outpatient facility or clinic instead of through the pharmacy benefit." Administration of the medication in the provider office or outpatient setting will remain a covered benefit under the medical plan.

This coverage change begins on Jan. 1, 2016, for all individual members, and will become effective for ASO, small group and large group members at the time of their plan renewal. To verify member eligibility and benefit requirements, please visit our Benefit Tracker tool at modahealth.com/EBTWeb/
AIM Specialty Health's clinical guideline expansion
Built on AIM Specialty Health's clinical guidelines, Moda's Diagnostic Imaging Management Services program strives to provide a streamlined approach to diagnostic imaging services. We do this by promoting the most appropriate use of advanced imaging services and encouraging the standardization of medical practice patterns to limit unnecessary radiation procedures, resulting in better safety outcomes and higher patient satisfaction.
The program currently includes outpatients (from hospital outpatient centers, free-standing imaging facilities and physician offices), elective CT scans, MRI, MRA and PET scans, and nuclear cardiology studies. Continuing our goal of applying best practices within healthcare, we will be adding 13 diagnostic imaging services to this program starting Jan. 1, 2016.
Order numbers required before diagnostic services
When ordering or referring a non-radiology physician for dates of service starting Jan. 1, 2016, providers must first contact AIM to obtain an order number before scheduling elective outpatient transthoracic and transesophageal echocardiograms. This change applies to all fully insured commercial, Medicare and Medicaid lines of business, as well as select administrative-services-only groups.
These codes include: 93350, 93351, 93303, 93304, 93306-93308 and 93312-93317.
As a reminder, radiology providers and free-standing imaging centers must confirm that an order number has been obtained prior to service delivery.
How to schedule services
To schedule services, please contact AIM toll-free at 877-291-0513, or visit them online at aimspecialtyhealth.com/marketing/goweb. After you register, follow the easy steps to request an order ID number through Provider Portal, AIM's interactive online application.
Please note: If services are not preauthorized, certain plans may apply a cost containment penalty even when services are authorized retroactively.
Medical provider workshops
To help your practice be its best, earlier this year our Medical Provider Relations team traveled across Oregon to keep you informed about network expansion news, ICD-10 updates, and online resources. If you missed us, click here to see our 2015 workshop presentation. While we've wrapped up our workshops for this year, you can stay informed by visiting  modahealth.com/medical/workshops.shtml.

We look forward to seeing you in 2016!
In this issue
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503-228-6554 | medical@modahealth.com |modahealth.com
601 S.W. Second Avenue
Portland, OR 97204