Claim edits policy

In a partnership with MagellanRX, on September 1, 2015, Moda implemented a claim check program for injectable and/or infusion medications.

The claim check program monitors and promotes appropriate use, safety, and cost effectiveness of medications prescribed to our members. We will do this by reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes.

This program will be limited to the following injectable and/or infusion medications, ordered or administered by providers. Moda applies post-service, pre-payment claims edits to diagnosis criteria and criteria for maximum units for the following medications. Prior authorization criteria do not apply for these medications. Please review the criteria below for specific covered diagnosis codes and dosing limits for each medication.

Name proc code
Cimzia J0717
Eligard J9217
Lupron Depot J1950
Emend J1453
Faslodex J9395
Gemzar J9201
Trelstar Depot J3315
Vantas J9225
Xofigo A9606
Zoladex J9202

As we gain better insight into utilization patterns, we will expand this initiative to cover and include more specialty and injectable drugs in the future. Updates will be posted to this page as the program is expanded.

This program will be limited to claims reviewed and to medications injected and/or infused in a professional office, home or outpatient setting.

Claims submitted after September 1, 2015 will be reviewed against clinical guidelines. If the services billed do not meet the guidelines, the claims will be subject to review and potentially disallowed.

We appreciate your partnership to improve the quality, value, and coordination of care for our members and your patients. As your partner in this evolving journey, we are committed to providing service excellence in process improvement.

Questions?

We're here to help. If you have questions, please contact our Provider Relations department at providerrelations@modahealth.com.

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