Changes to reimbursement for DRG payments (RPM066)
We are making some changes that will affect how we reimburse Diagnosis Related Group (DRG) facilities when a Moda Health member is transferred from a DRG facility to a different acute care hospital.
For discharge and transfer service dates
starting July 1, 2019
, when a DRG facility transfers an inpatient to a different inpatient hospital, the DRG facility will be paid a graduated per diem rate for each day of the patient’s stay in that hospital, not to exceed the DRG allowable amount. The per diem rate is based on a calculation defined by the Centers for Medicare and Medicaid Services (CMS).
A transfer occurs when a member:
- Transfers to a different acute care hospital for related care.
- Leaves against medical advice and is subsequently admitted to the same or different acute care hospital within 24 hours of leaving.
- Or is discharged, but then readmitted to another acute care hospital within 24 hours (unless the readmission is unrelated to the initial discharge)
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Reimbursement changes Anesthesia Modifiers (RPM032)
We are making some changes that will affect how we reimburse Anesthesia Physical Status Modifiers (P1-P6).
Effective for service dates
starting July 1, 2019
, Moda Health will align with CMS’s reimbursement policies. These changes include:
- Moda Health will no longer provide additional reimbursement for Anesthesia Physical Status Modifiers P1-P6 billed on Moda Medicare Advantage claims.
- Moda Health will not provide additional reimbursement for Anesthesia Physical Status Modifiers P1-P6 billed for OHP/EOCCO claims as modifiers P1-P6 are bundled in the payment for codes 00100-01999.
Moda Health will continue to provide additional reimbursement for Anesthesia Physical Status Modifiers P3-P5 that are billed on Commercial claims.
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Biosimilar products are safe, effective and cost-saving
The development of biologics has changed how we treat many common conditions such as autoimmune diseases and cancer. They are large molecules produced from living organisms. This process is more complex and expensive than conventional, small molecule drugs. Therefore, making a copy of a biologic (or “biosimilar”) is different from creating a generic version of a small molecule drug.
Biosimilars offer many benefits to patients, providers, and the healthcare system. They provide additional product options for patients and increase access to treatment. Increased competition results in reduced costs for the healthcare system and patients. Current projections indicate biosimilar products are expected to cost an average of 10% to 40% less than their reference products.
As biosimilar products enter the market, it is important to understand the biosimilar approval process so patients and providers have confidence in these safe, effective and cost-saving therapies. Learn more by choosing any of the following resources:
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Injectable medication expansion
The following prior authorization updates have been made to the injectable medications currently in the MagellanRX program.
Magellan Rx will review all 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
Effective July 1, 2019
- Velcade (J9041) – Primary cutaneous T-cell lymphoproliferative disorder will be removed as a covered indication.
Effective August 1, 2019
- Abraxane (J9264) – Uterine cancer, uveal melanoma, and subsequent treatment of advanced NSCLC will be removed as covered indications. Limited treatment in HER2-positive breast cancer to first-line therapy and use in HER2-negative disease to subsequent therapy.
- Marqibo (J9371) – Use in Philadelphia chromosome positive acute lymphoblastic leukemia will be removed as a covered indication.
- Onivyde (J9205) – Coverage is provided following prior gemcitabine-based therapy, use after fluoropyrimidine-based therapy will be removed as a covered indication.
- Yondelis (J9352) – Use in angiosarcoma will be removed as a covered indication, and use in rhabdomyosarcoma has been limited to translocation-related sarcoma subtypes.
- Halaven (J9179) – Use is HER2-positive breast cancer will be removed as a covered indication. The soft tissue sarcoma subtypes angiosarcoma and pleomorphic rhabdomyosarcoma will be removed as covered indications.
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Medical necessity criteria updates
Effective April 1, 2019
Effective May 1, 2019
Effective June 1, 2019
Effective July 1, 2019
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Moda Contact Information
Moda Medical Customer Service
For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email
medical@modahealth.com.
Moda Provider Services
Medical Professional Configuration
Credentialing Department
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In this Issue
Changes to reimbursement for DRG payments (RPM066)
Reimbursement changes for Anesthesia Modifiers (RPM032)
Biosimilar products are safe, effective, and cost-saving
Injectable medication expansion
Medical necessity criteria updates
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Go digital today!
If you want to start exchanging information electronically with Moda, please contact the Moda Electronic Data Interchange team at
edigroup@modahealth.com
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Join our email list
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Help us keep your practice details updated
To make sure we provide high-quality service to our members, Moda's Findcare online search tool helps members connect with our extensive network of contracted providers. To meet the CMS requirement of having updated information about your practice or facility for our members, please email our provider updates team at
- 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 make sure our members can find providers that are available and best suit their needs.
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