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.

With 2017 just around the corner, we'd like to make you aware of changes to our individual network.

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. 

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.

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.

Here are a few talking points if your patient is having difficulty with adherence:

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.

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.

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.

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

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.