Oregon  |  Spring 2016
New CMS 2016 procedure codes for drug screening/urine testing
CMS has developed new 2016 procedure codes (G0477 - G0483) for clinical drug testing used in pain management, substance abuse screening and treatment programs. Moda covers these clinical drug screening and testing services and follows their CMS coding guidelines. 
Key points you need to know: 
  • Moda accepts only CMS codes G0733 - G0483 for these testing services.
  • CPT codes 80300 - 80304 and 80320 - 80377 will be denied to provider liability if submitted.
  • No more than one unit of presumptive testing and one unit of definitive testing may be billed per service date.
  • No additional codes may be submitted for sample validation or specimen validity testing.
Our medical necessity criteria (Therapeutic Drug Monitoring) and our reimbursement policy RPM016 (Clinical Drug Screening and/or Drug Testing) have been updated to reflect the new 2016 codes. For more information, please see these policies.
Added coverage for preventive testing
Following requirements of the Patient Protection and Affordable Care Act, Moda covers preventive care services at 100 percent (no cost-sharing) for commercial and individually insured members when services are performed by an in-network provider. Moda also covers a limited list of non-mandated, category-two lab and diagnostic tests when billed with a routine preventive or screening diagnosis code. 
Effective December 1, 2015, 16 additional lab and diagnostic codes were added as covered non-mandated category-two tests. While these codes are covered by Moda, they are not included on the PPACA list of mandated preventive services, and therefore are not eligible for the 100 percent (no cost-sharing) preventive benefit. The tests will be covered but are subject to the member's usual cost-sharing and deductible requirements.
Lab and diagnostic services omitted from Moda's list of non-mandated, category-two procedure codes are covered when billed with a medical diagnosis code indicating symptoms or problems. They are considered non-covered and will be denied to provider responsibility if billed with a routine/preventive diagnosis code. 
For a complete list of covered, non-mandated category-two lab procedure and diagnostic service codes, please see reimbursement policy RPM037.
New guidelines for ancillary services related to colorectal cancer screening 
Moda covers preventive screening and related ancillary services for colorectal cancer in accordance with the Patient Protection and Affordable Care Act. Effective January 1, 2016, pathology services and specialty consultations prior to the screening procedure are also considered part of the preventive ancillary services and are covered at 100 percent (no member cost-sharing).
There are specific coding requirements that must be met for the member to receive preventive benefits for these services. Reimbursement policy RPM046 provides guidelines on proper coding specific to screening colonoscopies and ancillary services.
Deadline extended for Medicare Advantage prescriber enrollment
Last month, Moda sent a letter requiring Medicare Part D prescribers to enroll in (or validly opt out of) Medicare by June 1, 2016. Recently, CMS has decided to delay enforcement of this requirement until February 1, 2017. 
With the revised date, prescribers will have sufficient time to complete their enrollment activities. This delay will also provide Part D sponsors, pharmacy benefit managers and Medicare Advantage organizations offering MA-PDs additional time to finalize the system enhancements needed to comply with the Part D prescriber enrollment requirement.
Why it's important
Providers who currently prescribe medications for Medicare Advantage patients must enroll in (or validly opt out of) Medicare. Because of this new requirement, it is crucial for patient health that these providers enroll in Medicare (or validly opt out, if appropriate).
Please refer to the CMS Part D prescriber enrollment letter for further guidance on how to enroll or validly op out.
If you have questions, please contact CMS directly at providerenrollments@cms.hhs.gov. You may also visit the CMS Part D prescriber enrollment website for information about the new requirement or resources to check application status, or to sign up for the prescriber enrollment newsletter for updates.
YMCA's Diabetes Prevention Program 
In a collaborative effort to increase diabetes awareness and prevention, Moda is proud to offer type 2 diabetes education through the YMCA's Diabetes Prevention Program. The program teaches adults with prediabetes/at risk for developing type 2 diabetes about risk reduction strategies and how to incorporate physical activity and healthier eating habits into their daily lives.
The YMCA Diabetes Prevention Program is a covered benefit for Oregon Educators Benefit Board (OEBB) employees and Public Employees Benefit Board (PEBB) employees living in Marion and Polk counties. The program empowers adults to adopt lasting lifestyle changes that will improve their overall health and reduce their chance of developing type 2 diabetes.
Led by trained health coaches, the year-long program begins with 16 weekly sessions, followed by eight monthly sessions. Through healthier eating and increased physical activity, the program aims to reduce participants' body weight by seven percent, and maintain their physical activity for 150 minutes every week.
Diabetes affects nearly 26 million people. Another 79 million have prediabetes and are at risk of developing diabetes, but only 11 percent are aware of it. Research by the National Institutes of Health has shown that programs like the YMCA's reduce the number of new diabetes cases by 58 percent overall and by 71 percent in individuals over age 60.
Find additional information about the YMCA's Diabetes Prevention Program website.
To learn more, visit our Moda care programs website or email careprograms@modahealth.com.
New legislation regarding confidential member communication requests
In 2015, the Oregon state legislature passed House Bill 2758, allowing individuals who obtained health coverage on or after January 1, 2016, to request that confidential communications be sent to them separate from other members enrolled in the same coverage. Confidential communications include explanations of benefits, authorization details, requests for additional claim information and other communications that include protected health information.
Moda members may request confidential health benefit communications by filling out the Oregon - Request for Confidential Communication form found here. Completed forms may be faxed to our privacy office at 503-412-4068 or submitted by mail to:
Moda Health
Attn: Privacy Office
601 S.W. Second Ave.
Portland, OR 97204
HEDIS 2016 medical record review
We are excited to announce our kickoff of the HEDIS 2016 medical record review season. Each year we review a small sample of charts to evaluate quality measures. This year we are working on 10 quality measures. We will be partnering with Enterprise Consulting Solutions (ECS) and KDJ Consultants to collect and review charts. ECS and/or KDJ Consultants will be contacting you starting in February if any of your Moda members have been selected for chart review.  

HEDIS 2016 measures
  • Adult body mass index
  • Cervical cancer screening
  • Childhood immunizations
  • Adolescent immunizations
  • Colorectal cancer screening
  • Comprehensive diabetes care
  • Controlling high blood pressure
  • Human papillomavirus vaccine
  • Prenatal and postpartum care
  • 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. Email us at HEDIS@ModaHealth.com with your comments or contact information, and we'll be happy to provide details on the quality measures we evaluated at your practice. We are dedicated to providing the highest-quality care to our members and are grateful to have so many providers who continuously raise the bar in our HEDIS quality metrics.
For more information on the 2016 HEDIS medical record review, please see our FAQ.
About Ardon Health, our specialty pharmacy
Ardon Health is here to help patients on their health journey - and to assist you throughout the process of referring and treating your patients.

Ardon's concierge specialty prescription services save you time
You can expect fast and easy service - just send them a prescription and they'll do the rest. Services include:
  • Prescription benefits investigation and issue resolution
  • Prior authorization coordination
  • Financial and copay assistance for patients
  • 24/7 patient access to experienced pharmacists
  • Disease-specific individual care plans
  • Tailored medication counseling
  • Adherence monitoring and support
  • Side effect evaluation and interventions
  • Next-day medication delivery
  • Proactive refill planning and coordination
In addition, Ardon's clinical team monitors your patients and will contact your office if there is any concern (such as side effects, drug interactions, adherence issues or signs of disease progression). Ardon does all this so you can focus on caring for your patients.  

Not sure which specialty pharmacy your patient can use?
No problem. When you send Ardon a prescription, they investigate your patient's benefits. If the patient can't use Ardon, they transfer the prescription to the appropriate pharmacy.
Have questions about what financial assistance is available to your patients? Call Ardon, and they'll 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.

Please call toll-free at 855-425-4085 or email info@ardonhealth.com. TTY users, call 711.
Business hours:
Mon. - Fri., 8 a.m. to 7 p.m. PT
Sat., 8 a.m. to noon PT
We are closed Sundays and all major holidays.
24/7 pharmacist availability
New prior authorization list now available online
Complete with updated aesthetics and improved access to criteria, our new prior authorization website includes details on:
  • Which services need prior authorization
  • Which services may be non-covered or not medically necessary
  • Contact information to more efficiently request and route authorizations
Effective April 1, 2016, an updated HCPC/CPT-specific list of services that always require prior authorization can be found here. Because some services are considered investigational, cosmetic or not medically necessary, you can find a separate list of code-specific, non-covered services here.
Authorizations for advanced imaging studies are obtained through AIM Specialty Health. To place an authorization for advanced imaging studies, or to view a list of services which require prior authorization, login to AIM's Provider Portal at aimspecialtyhealth.com. For more information and codes requiring authorization, go to AIM's website, or call 877-291-0513.

Authorizations for selected Intravenous infusion or injectable drugs are obtained through Magellan Rx. For a complete list of Specialty Infusion/Injectable medications which require prior authorization, or to place an authorization, please login to MagellanRx's Provider Portal at mcg.com.
Medical necessity criteria updates
We've recently made a number of updates to our medical necessity criteria. You can find the following  changes  online at modahealth.com/medical/medical_criteria.shtml.
New Criteria
Changes to 
current criteria
Criteria in review

Air ambulance transport (available April 1, 2016)

Help us keep your practice details up to date
To ensure that 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 CMS requirement to have the most up-to-date information about your practice or facility available to 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 ensure that our members can locate providers that are available and best suit their needs.
In this issue
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For credentialing questions and requests, please email 

503-228-6554 | medical@modahealth.com |modahealth.com
601 S.W. Second Avenue
Portland, OR 97204