Oregon  |  May/June 2016
Keep your practice connected
We strive to keep your practice connected with billing updates, policy changes, provider network news and helpful tips to ensure timely reimbursement and maximized efficiency when working with our members.

In an effort to save you time, Moda is consolidating the Medical Provider Newsletter to a bi-monthly schedule. Covering a wide variety of topics, the newsletter will focus on timely communication to support transparency in the development and implementation of process changes and enhancements.

We'd love to hear from you!
Is there a topic you'd like us to cover? If so, email us at providercommunication@modahealth.com.
Network changes for the 2017 plan year
With 2017 just around the corner, we'd like to make you aware of changes to our individual network.
  • Our 2017 individual network features an Oregon-based integrated healthcare provider system that provides high value and cost-effective healthcare services to all individual health plan policyholders. To achieve improved health outcomes, the network's Clinical Integration Program brings together Moda and our hospital system partners to ensure patients receive quality care.
  • For the 2017 plan year, we've partnered with nine health systems, including Asante, Bay Area Hospital, Columbia Memorial, Mid-Columbia, OHSU, Portland Adventist, Salem Health, Tuality and Willamette Valley Medical Center. Our new Beacon Network will be available in 13 counties, including Clackamas, Clatsop, Columbia, Coos, Hood River, Jackson, Josephine, Marion, Multnomah, Polk, Wasco, Washington and Yamhill.
As a valued partner in supporting healthy communities, we look forward to continuing to drive the goal of achieving the Triple Aim - Better health. Better care. Better value. 
Moda partners with Medversant to enhance medical provider credentialing 
We've partnered with Medversant Technologies to perform streamlined credentialing and re-credentialing application processing through their secure online portal, ProviderSource. The online credentialing and re-credentialing portal now gives providers a web-based credentialing application to streamline their credentialing process.
Effective April 25, 2016, medical provider credentialing and re-credentialing applications must be submitted electronically through Medversant's ProviderSource web portal.

This tool allows providers to become credentialed in less than 30 days, and gives 24/7 access to the status of one's credentialing or re-credentialing application in real time. Providers must complete the credentialing process through ProviderSource, and be approved prior to treating Moda members.
Moda will continue to perform credentialing services for facilities and dental providers, as well as review and monitor past and present malpractice claims, state licensing disciplinary activity, adverse outcomes, medical record keeping, office site, and member access to providers and surveys.
For questions about credentialing with Moda, please contact us at 855-801-2993 or credentialing@modahealth.com.

For questions about Medversant's ProviderSource credentialing portal, please call a Medversant representative at 888-308-3895, or visit modahealth.providersource.com.
Provider workshops coming this fall!
Your Moda Provider Relations team is gearing up for our 2016 provider workshops! These workshops will be held at the following locations starting in September:
  • Medford
  • McMinnville
  • Ontario
  • Coos Bay
  • Seaside
  • Lincoln City
  • The Dalles
  • Eugene
  • Salem
  • Bend
  • Pendleton
  • Portland
  • Hillsboro

Look for your invitation 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.
Qualifying circumstances for anesthesia 
We recently updated our policy for CPT codes 99100 - 99140, which describes qualifying circumstances for anesthesia. The Centers for Medicare and Medicaid Services (CMS) assigns these codes a status indicator of "B" bundled. CMS' explanation of the work value of services described by status "B" procedure codes is that they are included in the RVU values for the main services and procedure codes to which status "B" code(s) are incident; in the case of 99100 - 99140, that means the primary anesthesia procedure codes.

Effective for claims processed on or after 2/25/2016 and applicable to all commercial, Medicare Advantage, and Medicaid plans, Moda does not separately reimburse for CPT codes 99100 - 99140 qualifying circumstances for anesthesia. The updated policy is available at modahealth.com/pdfs/reimburse/RPM033.pdf.
Presumptive and definitive drug testing: What you need to know
In an effort to standardize billing practices, CMS reclassified "quantitative" drug tests as "definitive." Moda considers definitive tests as medically necessary only in the presence of a positive presumptive test. Billing definitive tests in the absence of presumptive test can result in significant non-covered charges. Moda's medical necessity criteria for these tests can be found at modahealth.com under Therapeutic Drug Monitoring.

The clinical value of indiscriminate definitive testing has not been established, and the unintended consequences of the uncovered labs can be severe. 

Monitoring for drug use is critical for a patient's success. To ensure the best outcomes for patients, we encourage providers to be certain that any tests ordered be both medically necessary and covered under a patient's benefit plan. This way, we can provide the best possible support and outcomes for patients' ongoing recovery.
Adherence to antidepressants
Medication adherence is one of the greatest determinants of successfully treating major depressive disorder, one of our country's most common health disorders. According to the 2000 Annals of Internal Medicine - Pharmacologic Treatment of Acute Major Depression and Dysthymia, 35 percent of patients who stop antidepressant therapy prematurely relapse within six months. Educating your patients about how antidepressants work, benefits of treatment, symptom remission expectations, and coping with side effects may significantly improve their medication adherence.

Here are a few talking points if your patient is having difficulty with adherence:
  • Taking daily medications will prevent missed doses and improve compliance.
  • Using pillboxes, phone alarms, medication-tracking logs and email reminders can help manage medication schedules.
  • Symptoms may improve within two weeks of initial therapy, but may need more time to demonstrate full response and/or remission.
  • Taking prescribed medications will give the greatest health benefit and may reduce the need for additional medications.
  • Talk to your doctor if you are thinking about stopping your medication. Do not abruptly stop taking your medication, even if symptoms of depression subside.
Moda offers mail-order pharmacy and 90-day supplies to certain members. Please have your patient contact a Moda team member at 503-243-3960 to see if they quality.
Appropriate use of LT and RT modifiers
Modifiers LT and RT are only considered valid for procedure codes with descriptions that specifically identify procedures that can be performed on body parts existing twice in the body - once on the left and once on the right (paired body parts) such as eyes, ears, arms, and legs. Modifiers LT and RT should be used when a procedure was performed on only one side of the body to identify which one of the paired organs was operated upon.

LT and RT modifiers are not considered valid for fingers, toes, tendons, nerves, drugs (E-codes, J-codes) or laboratory services (80000-89398). The CMS guideline can be found in Transmittal No. A-00-73, dated October 5, 2000.

Refer to Moda's Reimbursement Policy RPM019 ("Valid Modifier to Procedure Code Combinations") for more details.
Updated online prior authorization list now available
Our prior authorization website details services that always require prior authorizations. Because some services are considered investigational, cosmetic, or always not medically necessary, the site includes a separate list  identifying codes for services that are not covered or not medically necessary. It also includes contact information to more efficiently request and route authorizations.

Authorizations for advanced imaging studies are obtained through our partner, AIM Specialty Health. To place an authorization for advanced imaging studies or to see a list of services requiring prior authorization, log in to AIM's provider portal. For more information, call 877-291-0513 or visit AIM's website.

Authorizations for selected intravenous infusion or injectable drugs are obtained through Magellan Rx. For complete list of specialty infusion/injectable medications that require prior authorization, please visit modahealth.com/medical/injectables.
New provider-administered medications for prior authorization
As part of our commitment to providing our members with high-quality, affordable care, we've partnered with Magellan Rx Management to assist you in medical pharmacy management through the provider administered injectable drug program. We will also continue to implement updates to the review and approval processes of certain injectable medications.
Effective July 1, 2016, 17 new medications will be added to the prior authorization list of medications requiring authorization in the Magellan Rx program. Please visit our website to view the complete list.

Magellan Rx will review your prior authorization requests 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
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 place an authorization, log in to MagellanRx's
Reconsiderations for a prior authorization request with new and/or additional information must be submitted directly to Magellan Rx within 30 days of a denied prior authorization. If it is after 30 days or there is no new information, you can submit an appeal or a new authorization request. Moda will not perform reconsiderations or peer-to-peer for Magellan Rx prior authorizations.
To learn more about our injectable drug program, please check out our Injectable Drug Program FAQ.
We appreciate your support in assuring our members receive quality care. If you have any questions, please call our Customer Service team toll-free at 800-258-2037.
Formulary change for insulin products
Beginning July 1, 2016, Humalog and Humulin insulin products will require a prior authorization and move from preferred tier 2 to non-preferred tier 3 on the Moda Health Preferred Drug List (tiering of concentrated Humulin R U-500 will remain unchanged). This formulary change only affects large group commercial plans. Individual and small group plans are not affected by this formulary modification. Please see the list below for cost-effective alternative drug(s) similar in safety and efficacy that may be a treatment option. The following insulin medications will not require prior authorization.
  • Novolog
  • Novolin 70-30
  • Novolin N
  • Novolin R
  • Novolog Flexpen
  • Novolog Mix 70-30
  • Novolog Mix 70-30 Flexpen
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 our medical necessity criteria website.
Changes to current criteria 
In this issue
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Visit our website  and click on "Join our email list" in order to begin receiving quarterly newsletters, as well as occasional electronic communications.
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.
Go digital today!
If you would like to start exchanging information electronically with Moda, please contact the Moda Electronic Data Interchange team at 
Moda Contact Information 
Moda Medical Customer Service
For claims review, adjustment requests and/or billing policies, call 
(888) 217-2363 or email medical@modahealth.com.
Moda Provider Services
To reach our Provider Services department, please email 

Medical Professional Configuration
For provider demographic and address updates email 
Credentialing Department
For credentialing questions and requests, please email 

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