Oregon |May/June 2019
Important changes to reimbursement revenue codes (RPM042)

We are making some important changes that affect how we reimburse for revenue codes ending in “9” (“Other” categories). To help ensure accurate coding and accurate data collection in our claims processing of revenue codes, we are updating our configuration for consistency across all of the unlisted “other” category revenue codes. Moda Health considers revenue codes for “Other” (ending with 0XX9) to be unlisted revenue codes, which we do not accept.

Effective Aug. 1, 2019 , and applicable to all Moda commercial, Medicare Advantage and EOCCO/OHP plans, any service reported with a revenue code ending in “9” will be denied and the provider will be held responsible.
 
Please consider the following options before entering the revenue code:
  • Instead of using an unlisted “other” revenue code ending in “9,” use a more specific revenue code ending in “1,” “2,” “3,” “4,” “5,” “6,” “7” or “8.” If you can’t find one, a general revenue code (ending with “0,” e.g. 0XX0) may be used when there is no CMS requirement to use a specific revenue code. 
  • Do not use an unlisted “other” revenue code ending in “9” to report services. These codes will be denied as member responsibility (e.g. excluded from the member’s plan coverage, investigational, non-medical items or services, etc.). Please report with a HCPCS code to clearly identify the non-covered service, even if the revenue code used does not require a HCPCS code.

You can view our “Revenue Codes Ending in 9 (Other Categories)” reimbursement policy at modahealth.com/pdfs/reimburse/RPM042.pdf . Or see a complete list of our reimbursement policies .
City of Portland MagellanRx

Starting Sept. 1, 2019 , the City of Portland will be included in Moda Health’s partnership with Magellan Rx Management. This partnership has three components to helping members access high quality, affordable care.
 
Provider-administered Injectable Drug Program:
Prior authorization is required for specific injectable specialty medications administered in one of these settings:

  • a patient’s home
  • a physician’s office
  • an outpatient facility
 
Completing prior authorization requests through Magellan Rx will help expedite claims processing and doesn’t require you to submit medical records.
 
To begin requesting prior authorizations through the Magellan Rx self-service portal, log in to Magellan Rx website and select “New Access Request-Provider.” You may also see which medications require prior authorization
 
Site of Care program:
Certain provider-administered medications will only be authorized in an outpatient setting or in the patient’s home. If you submit a prior authorization request to provide one of these medications in a hospital outpatient center, you will be redirected to a preferred home infusion provider or an outpatient office setting. Exceptions to this policy may be granted on a case-by-case basis based on medical necessity.
 
Learn more about the Site of Care program’s current list of medications .
 
Claim edits program :
Moda Health has partnered with Magellan Rx to expand its claim check program to monitor and promote appropriate use, safety and cost effectiveness of the medications prescribed to our members.

Medications included in the claim check program are not subject to prior authorization. Moda applies post-service, pre-payment claims edits to diagnosis criteria and criteria for maximum units for all medications included in this program.

View a list of medications included in the Claim edits program.

Questions?
We’re here to help. Just email medical@modahealth.com or call 800-258-2037.
Biosimilar preferred strategy

To provide members with high quality, affordable care, Moda Health will require the use of FDA-approved biosimilars prior to the reference product (also known as the originator biologic or innovator product) for the treatment of certain oncology and non-oncology indications.

Effective Sept. 1, 2019, Moda members initiating treatment with bevacizumab, rituximab or trastuzumab will be limited to the biosimilar product(s) outlined below, when commercially available. If there is clinical documentation that all available biosimilar products are contraindicated or not tolerated, the reference product may be considered for coverage.

For members currently receiving treatment with a reference product, prescribers may choose to transition to a biosimilar or continue their current regimen. Keep in mind that members may have lower out-of-pocket costs with biosimilar products.
* FDA-approved products as of June 3, 2019. Commercial availability pending. 

Magellan Rx will continue to review prior authorization requests for all fully insured group and individual members, and select ASO groups. Moda will review all other members.
 
Get started today!
Follow these easy steps to start requesting prior authorizations through the Magellan Rx self-service portal:
  1. Log in to the Magellan Rx website
  2. Select “New Access Request – Provider” on the right side of the home page


Questions?
We are here to help. Please email medical@modahealth.com or call us at 877-605-3229.
Coverage changes for Infused Specialty Medications (OEBB & PEBB)

Moda Health and Ardon Health have expanded the management of specialty medications to include infused medications. The program expansion aims to enhance the member experience through consistent, quality service, improved reporting and lower out-of-pocket costs.

Beginning Oct. 1, 2019, for Oregon Educators Benefit Board (OEBB) members, and starting Jan. 1, 2020 for Public Employees’ Benefit Board (PEBB) members, the following infused specialty medications will onl y be covered under the pharmacy benefit. Any claims submitted under the medical benefit will be denied as provider liability. Claims for the administration of the medication should continue to be billed to the member’s medical benefit.
These prescriptions should be sent to Ardon Health or participating pharmacies for processing and fulfilment rather than being obtained through the “buy and bill” process. Please note: Ardon Health does not have access to Spinraza at this time; it should be obtained from a participating pharmacy.

You can submit a prior authorization request for the infused specialty medications listed above through the CoverMyMeds ePA tool . Members may also contact Ardon Health or participating pharmacies directly.

See a complete list of infused specialty medications covered only under the pharmacy benefit. New medications may be added to the list at the time of FDA approval.

Questions?
We are here to help. Please email medical@modahealth.com or call us at 877-605-3229.
Euflexxa named preferred product for viscosupplementation injections

To provider our members with high quality, affordable care, Moda Health has selected Euflexxa as the exclusively preferred hyaluronic acid product for viscosupplementation injections.

Effective July 20, 2019 , Moda members who receive hyaluronic acid injections will be limited to the preferred product. Those currently receiving hyaluronic acid injections with a non-preferred product may complete their current course of therapy.

Magellan Rx will review prior authorization requests for all fully insured group and individual members, and select ASO groups for hyaluronic acid injections. This includes the following hyaluronic acid products. Hyaluronic acid injections provided to all other members will be reviewed by Moda.
If a clinical document shows that Euflexxa is ineffective, not tolerated or contraindicated, an alternate hyaluronic acid product may be considered. Please note that trial and failure of Euflexxa is required by the plan before using other hyaluronic acid injections, unless it is a medical necessity.
 
Get started today!
Follow these easy steps to begin requesting prior authorizations through the Magellan Rx self-service portal:
  1. Log in to the Magellan Rx website
  2. Select “New Access Request – Provider” on the right side of the home page

Learn more about our hyaluronic acid injection requirements on our medical necessity criteria web page .

Questions?
We are here to help. Please email medical@modahealth.com or call us at 877-605-3229.
Generic insulin products

Did you know that Moda Health has offered branded insulin products such as NovoLog® and Novolin® at a generic copay or cost share to our commercial members for several years? The following are brand insulin products on the generic tier:
We recognize the availability of a similar insulin, the authorized generic of HumaLog®, as a step in the right direction for lowering costs. However, Novolin and NovoLog will remain on the generic tier as they are still the most affordable insulin products for our commercial members. 
Injectable medication updates

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 Oct. 1, 2019

Avastin (J9035) – Use for HER-2 negative breast cancer, platinum-sensitive ovarian cancer, and use in combination with pemetrexed (Alimta) for NSCLC, will be removed as a covered indications. 

Learn more about the injectable medication program and view the current medication list .
Recent reimbursement and Medical necessity policy updates

The following changes were recently made to our reimbursement policies and medical necessity criteria:

Reimbursement policies


Learn more on our   reimbursement policy page.

Medical Necessity criteria

  • Breast Implant RemovalClarified the medical treatment with an indication that if breast cancer is associated with anaplastic large cell lymphoma, then it meets the criteria.
  • Gender reassignmentDeleted duplicate language from the adolescent criteria. Verified and expanded codes that were within ranges.
  • Spinal cord stimulators — Added a specified coverage period for a trial of spinal cord stimulation. Specified the conservative methods of pain management to be considered. Also updated the criteria to be considered for coverage when the trial of spinal cord stimulation for the management of intractable angina is requested.
  • Vagus nerve stimulators — Updated the criteria and removed deleted codes.

Learn more on our   medical necessity criteria page.
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
For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests please email providerrelations@modahealth.com.

Medical Professional Configuration
For provider demographic and address updates, please email providerupdates@modahealth.com.

Credentialing Department
For credentialing questions and requests, please email credentialing@modahealth.com.
In this Issue

Important changes to reimbursement revenue codes (RPM042)

City of Portland MagellanRx

Biosimilar preferred strategy

Coverage changes for Infused Specialty Medications (PEBB and OEBB)

Euflexxa named preferred product for viscosupplementation injections

Generic insulin products

Injectable medication updates

Recent reimbursement and Medical necessity policy updates
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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
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 make sure our members can find providers that are available and best suit their needs.

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