Moda Health clinical editing and administrative best practices
Our medical claims processing uses clinical edits that follow CMS/Medicare coding guidelines, along with other industry standard guidelines to help settle claims. These guidelines include AMA, CPT and HCPCS. To enhance clinical editing for professional and facility claims, moving forward we will standardize clinical editing and reimbursement policies to more closely follow CMS for all lines of business.
Co-surgeons/team surgeon indicators
For claims processed on
July 29, 2018, and after, we will apply the co-surgeon and team surgeon indicators on the CMS Physician Fee Schedule. Please note the following:
- Per CPT guidelines, TAVR/TAVI procedure codes (33361-33369) require two physicians; you must report all components with modifier 62
- Co-surgeon indicator “0” — We will deny procedure codes not eligible to be billed with modifier 62
- Co-surgeon indicator “1” — Procedure codes require that you submit supporting documentation to prove medical necessity of two surgeons/modifier 62. Depending upon the review results, we may deny the line item with modifier 62.
- Team surgeon indicator of “0” — We will deny procedure codes not eligible to be billed with modifier 66
- Team surgeon indicator of “1” — Procedure codes require that you submit supporting documentation to prove medical necessity of team surgeons/modifier 66. Depending upon the review results, we may deny the line item with modifier 66.
To learn more, see
RPM035
, “Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons).”
Radiology modifiers
We also follow CMS policy for situations outside of clinical editing software that are not specifically mentioned in the Moda Health Reimbursement Policy Manual (see
RPM001). Please remember, this applies to a variety of less-frequent radiology circumstances, including:
- Modifier FX (X-ray taken using film)
- You must append Modifier FX when X-rays are taken with traditional film rather than digital radiography equipment
- A 14 percent payment reduction applies to the technical component, whether billed as a separate component or part of the global fee (see MM9727)
- Modifier CT (Computed Tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturing Association [NEMA] xr-29-2013 standard)
- You must use Modifier CT for professional (CMS1500) claims for services furnished on non-NEMA Standard XR-29-2013-compliant CT scanners
- A payment reduction of 15 percent applies to the technical component, whether billed as a separate component or part of the global fee (see CMS Pub. 100-04, ch. 12, § 20.4.7)
- You must submit portable X-ray procedure code R0075 with one of the following modifiers, UN, UP, UQ, UR or US. We will prorate the allowable amount for R0075 for the number of patients served (see MM4039).
Modifier EY (No physician or other licensed healthcare provider order for this item or service)
CMS guidelines require that Durable Medical Equipment Prosthetic and Orthotic Supplies (DMEPOS) items have a prescription from the treating physician. If the supplier has received a prescription for some, but not all of the items provided to the member, the supplier must submit two separate claims.
One claim will be for the items with a physician order and the other for the items with no physician order. Modifier EY needs to be added to each line item. These guidelines are for all lines of business, including Commercial. Please note if you mix ordered items (without modifier EY) and no-order items (with modifier EY) on the same claim, we will deny the claim and ask for a corrected claim.
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Injectable medication expansion
Effective Oct. 1, 2018, three 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
The new prior authorization medications include:
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To learn more about the Injectable medication program and view the current medication list
here
.
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Site of Care expansion
Effective Oct. 1, 2018, the following medications will be added to the Site of Care specialty infusion program for all fully insured Commercial and EOCCO members:
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These medications already require prior authorization through Magellan Rx and the site of care requirements will be administered as part of the existing prior authorization program.
To prevent a delay in care and allow adequate transition time for Moda members to an alternate infusion site, Site of Care program requirements will be waived for the first sixty (60) days only after prior authorization approval so that members can transition to a different infusion site.
Learn more about the Site of Care program and view the current medication list
here
.
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Medical necessity updates
We've recently updated our medical necessity criteria which is
effective May 24, 2018. You can find the following changes at our
medical necessity criteria page.
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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
Moda Health clinical editing and administrative best practices
Injectable medication expansion
Site of Care expansion
Medical Necessity 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
Visit
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Help us keep your practice details updated
To make sure 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 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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