Moda Health Prior Auth & Utilization Rules

inv-01: Prior authorization and review criteria

Covered when the following prior authorization and notification requirements are met:

All urgent/emergent inpatient admissions require notification to Moda Health within 48 hours of admission.

See notification timeframe.

Prior authorization is required for all inpatient elective admissions to an acute care facility; must meet the policy definition of an 'emergency medical condition'.

Prior authorization is required prior to admission for skilled nursing, inpatient rehabilitation facilities, and long term acute care facilities.

Prior authorization is required for transplant evaluation and the transplant event.

Prior authorization is required for advanced imaging and musculoskeletal services for members enrolled in eviCore programs; authorization is obtained through www.eviCore.com and program/code lists on modahealth.com.

Prior authorization is required for select specialty and self-injectable drugs; drug authorizations are obtained via Magellan RX Management for fully insured groups or via the Moda Pharmacy benefit (contact Pharmacy Customer Service) for other groups.

Therapeutic drug monitoring (Urine Drug Testing) is reviewed for medical necessity on claim submission; limits of 12 presumptive and 12 definitive tests apply; certain presumptive UDT codes (e.g., 0227U) are Not Covered effective 1/1/2021.

DME requests of $500 or more require prior authorization or may be reviewed for medical necessity upon claim submission.

Authorizations for intensive outpatient rehabilitation for autism spectrum disorder and neurodevelopmental conditions must be obtained from Moda Health (do not send to eviCore).

Participation in clinical trials will be reviewed for medical necessity; trial documentation (trial number, chart notes, protocol and signed consent) should be sent to the Medical Director; prior authorization is not required but will be reviewed with claim submission.

Providers may verify prior authorization requirements via Benefit Tracker (EBTWeb) or by calling Moda customer service; Texas members may use ashlink.com for eligibility/benefit verification.

inv-02: Observed code mappings (informational)

Observed code equivalencies and cross-references (informational):

T2048 maps to H0010, H0017, H0018, H0019 for Residential Mental Health / psychiatric residential treatment (children and adults).

T2048 is cross-referenced with residential substance use disorder codes H0011, H0012, H0013 and also mapped to H0010, H0017, H0018, H0019; ASAM mapping referenced in crosswalks.

inv-03: Prior authorization requirements

Authorization and medical necessity review requirements and routing:

Use Moda Health Medical Necessity Criteria (MHMNC) or MCG guideline references where indicated for clinical medical necessity reviews.

Route drug authorization requests: Magellan RX handles authorizations for many drugs for fully insured groups and individuals; other groups should contact Moda Pharmacy/HCS; select self-injectables may be reviewed by Pharmacy RX as noted.

Advanced imaging and specified cardiology procedures require prior authorization through eviCore (www.eviCore.com) for members enrolled in eviCore; groups without eviCore obtain PA through Moda Health/HCS.

inv-04: Residential behavioral health mappings

Behavioral health residential code mapping (informational):

Residential SUD and Mental Health HCPC code mappings: T2048 appears paired with H0011, H0012, H0013 (residential SUD) and is mapped to H0010, H0017, H0018, H0019 (residential mental health); ASAM references appear in mapping text.

inv-05: Device and CGM coverage

Device coverage notes and exclusions:

Active cooling devices (e.g., Game Ready) are not covered (considered not covered in MHMNC Cooling Devices section).

Continuous glucose monitors reference MHMNC CGM guidance and list CPT/HCPCS codes (95249, 95250, K0553, K0554, A9276–A9278); effective date/code updates are noted in the device list.

inv-06: Procedures and specialty drugs

Interventional procedures and specialty drug authorization routing:

Epidural, facet, medial branch blocks and SI joint injections are reviewed by eviCore for groups enrolled in advanced imaging/cardiology or interventional pain programs; note that CPT 64483 for SI injections is reviewed by Moda Health.

Many specialty drugs require prior authorization: Magellan RX processes authorizations for fully insured groups/individuals; other groups contact Moda Pharmacy/HCS; some drugs or select ASO/Oregon groups may be routed to Pharmacy RX as specified.

inv-07: Surgical management coverage

Surgical management coverage references and criteria:

Gender-affirming surgery requires prior authorization and follows MCG Gender Affirming Surgery guidance; covered for Oregon fully insured groups and individuals—check member handbook for ASO or Alaska-specific language.

Gastric bypass and restrictive procedures follow MHMNC Obesity: Surgical Management criteria; check member handbook for specific benefit details and applicability to ASO groups.

inv-08: Coverage determinations and routing

Coverage determinations and routing for items noted investigational or with special claims review:

Interspinous decompression and interlaminar stabilization devices (e.g., CPT 22867–22870, C1821) are no longer covered and are considered investigational as of 10/1/2016.

Intraoperative neurophysiologic monitoring does not require prior authorization; medical necessity will be reviewed at claim submission.

Intravenous Immune Globulin (IVIG) and Subcutaneous Immune Globulin (SCIG) codes (including J1576 effective 7/1/2023 and related codes) require authorization routing as listed (Magellan RX for fully insured groups; other groups contact Moda Pharmacy/HCS).

inv-09: PA exemptions and routing notes

PA exemptions and routing notes (procedures and services):

No prior authorization required for selected codes

Selected laser wart removal and related dermatologic procedure codes (examples: 17000, 17003, and specific 17106–17111 entries) have no prior authorization required per effective dates noted.

Hip and knee replacements and other joint surgeries are reviewed for medical necessity; for members enrolled in the eviCore MSK program, prior authorization is obtained through eviCore—check EBT for enrollment.

Knee arthroscopy and related knee surgeries require prior authorization for fully insured members; eviCore handles PA for groups enrolled in the MSK program otherwise follow Moda routing and check EBT for enrollment status.

inv-10: Authorization and routing rules

Authorization routing and coverage determination references:

PET scans require prior authorization: groups enrolled in eviCore use eviCore; groups without eviCore obtain PA through Moda Health/HCS.

Spinal surgeries and spinal cord stimulator services require prior authorization; for members enrolled in eviCore MSK, authorization is obtained through eviCore; otherwise obtain PA via Moda Health/HCS.

Selected specialty drugs (listed J-codes and HCPCS) require prior authorization; Magellan RX handles authorizations for fully insured groups and individuals; other groups contact Moda Pharmacy/HCS.

inv-11: Authorization routing and guideline references (S-Z segment)

Vendor-specific authorization and guideline references (procedures/services S–Z):

For members enrolled in eviCore MSK, prior authorization for listed MSK procedures (including some joint surgeries and spinal cord stimulator services) must be obtained through eviCore; check EBT for enrollment and the provider website for procedure listings.

Magellan RX processes authorization requests for many specialty drugs and biologics for fully insured groups and individuals; groups not covered by Magellan RX should contact Moda Pharmacy/HCS for authorization processing.

Refer to cited MCG or MHMNC guideline IDs for clinical criteria where listed (examples include MCG S-420 Elbow Arthroplasty, MCG S-634 Shoulder Arthroplasty, and other MCG/MHMNC references shown in the procedure lists).

Prior authorization for inpatient admission for drug administration (e.g., CAR-T and other infusion therapies) requires drug authorization prior to requesting the inpatient admission.

Codes and code groups referenced

Behavioral health inpatient/residential codesCPT

H0010	Residential mental health / psychiatric residential treatment related code referenced
H0017	Residential/inpatient mental health code referenced
H0018	Residential/inpatient mental health code referenced
H0019	Residential/inpatient mental health code referenced
T2048	Residential/Substance use disorder / psychiatric residential treatment code referenced
H0011	Inpatient substance use disorder / mental health code referenced

Behavioral health inpatient/residential codes (mapping note)mixed

T2048 -> H0010,H0017,H0018,H0019

T2048 mapped to residential mental health codes per MHMNC

Urine drug testing codesCPT

G0480	Therapeutic drug monitoring
G0481	Therapeutic drug monitoring
0227U	Presumptive UDT code listed as Not Covered effective 1/1/2021

Residential mental health and SUD codesmixed

T2048	Residential Mental Health / Residential Substance Use Disorder
H0010	Behavioral health services, residential
H0017	Behavioral health services, residential
H0018	Behavioral health services, residential
H0019	Behavioral health services, residential
H0011	Residential substance use disorder services
H0012	Residential substance use disorder services
H0013	Residential substance use disorder services

Residential behavioral health code mappingsHCPCS

T2048	Residential services mapping (appears paired with H0011/H0012/H0013)
H0011,H0012,H0013	Residential substance use disorder / residential mental health HCPC/CPT codes referenced
H0010,H0017,H0018,H0019	Residential mental health/substance use codes referenced as equivalents

Partial Hospitalization / IOP codesHCPCS

H0035,H2012,S0201	Partial Hospital Program mental health / partial hospitalization codes
S9480	Intensive Outpatient Treatment code

Therapy and TMS codesCPT

97151-97158,0362T,0373T	Applied Behavioral Analysis codes
90867-90869	Transcranial Magnetic Stimulation codes

Drug and surgical authorization codesmixed

J-codes and procedure codes listed (examples: J9264, J3262, J0597, 22856-22865, 29805-29999)

Drug and surgical/procedural codes requiring authorization per list

Bariatric and gender-affirming surgery codes (examples)CPT

43644	Example restrictive procedure for obesity management
43770	Gastric restrictive procedure example
43771	Gastric restrictive procedure example
43772	Gastric restrictive procedure example
43773	Gastric restrictive procedure example
43774	Gastric restrictive procedure example
43775	Gastric restrictive procedure example
43886	Gastric bypass/restrictive procedure example
43887	Gastric bypass/restrictive procedure example
43888	Gastric bypass/restrictive procedure example

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Genetic testing codes and new/updated molecular codesCPT

81479	Unlisted genetic test code (listed among genetic testing entries)
81599	Unlisted genetic test code (listed among genetic testing entries)
0234U	Molecular/genetic panel code example
0285U	New/updated molecular/genetic code (1/1/2022 noted)
0388U	Molecular/genetic code listed
81560	Genetic testing code (new 1/1/2022)
81523	Genetic testing code (new 1/1/2022)
81441	Genetic testing code (effective 1/1/2023 noted)
81449	Genetic testing code (effective 1/1/2023 noted)

Selected specialty drug J-codesHCPCS

J1411	Hemgenix (etranacogene dezaparvovec-drlb) example
J0178	Example specialty drug J-code
J9355	Herceptin (trastuzumab) J-code example
J9356	Herceptin (trastuzumab) J-code example
J3060	Example specialty drug J-code

Selected specialty drug HCPCSHCPCS

J1306

Leqvio

DME / Orthotics codesHCPCS

L0450	Spinal orthosis example
L0622	Orthotics example

Orthotics/DME codesHCPCS

L3671	Orthosis, listed among lumbar/upper extremity orthoses
L1900	Ankle/foot orthotics codes (examples)
E0424	Portable oxygen equipment

Imaging/surgery codesCPT

95807	Polysomnogram in-lab
63663	Spinal surgery related code

Specialty drug J-codesJ-code

J1745	Infliximab (Remicade) infusion
J9312	Rituximab (Rituxan)

Vagus nerve stimulator new/effective codesCPT

64582	New vagus nerve stimulator code (effective 1/1/2022 listed)
64583	New vagus nerve stimulator code
64584	New vagus nerve stimulator code
61889	VNS code effective 1/1/2024
61891	VNS code effective 1/1/2024
61892	VNS code effective 1/1/2024
64596	VNS code effective 1/1/2024
64597	VNS code effective 1/1/2024
64598	VNS code effective 1/1/2024

Sample drug HCPCS/CPT codes in segmentmixed

J2326	Spinraza (nusinersen)
J1627	Sustol
J2779	Susvimo
J2781	Syfovre
J2860	Sylvant (Siltuximab)
90378	Synagis (palivizumab)
J9262	Synribo

UDT limits — Therapeutic Drug Monitoring

Urine drug testing (UDT) limits12 presumptive tests and 12 definitive tests (limits apply as of 6/1/16)

Presumptive UDT not-covered exampleCPT/HCPCS code 0227U listed as Not Covered effective 1/1/2021

Review pathwayUDT is reviewed for medical necessity on claim submission; refer to Moda Health Medical Necessity Criteria

DME prior authorization threshold

DME prior authorization thresholdDME requests of $500 or more require prior authorization or may be reviewed for medical necessity upon claim submission

Claim review optionDME items under $500 may still be reviewed for plan benefit availability or medical necessity

Reference guidanceCMS guidelines applied for prior authorization unless otherwise stated in Moda Health criteria

What providers must do (authorization routes, documentation, contacts)

Prior Authorization

Prior authorization and notification requirements

Prior authorization is required for all inpatient elective admissions to an acute care facility; prior authorization is also required prior to admission for skilled nursing, inpatient rehabilitation facilities, long term acute care, and for transplant evaluation and the transplant event. All urgent/emergent inpatient admissions must be reported to Moda Health within 48 hours of admission.

Prior authorization required for inpatient elective admissions (must meet definition of an "emergency medical condition").
Prior authorization required prior to admission for skilled nursing, inpatient rehabilitation, and long term acute care.
Prior authorization required for transplant evaluation and transplant event.
Urgent/emergent admissions: notification to Moda Health within 48 hours.

Documentation Required

eviCore authorization pathway

Authorization for advanced imaging and musculoskeletal services for members enrolled in eviCore programs must be obtained through www.eviCore.com; lists of programs and procedure codes are available on modahealth.com/utilizationmanagement.

Use www.eviCore.com for authorizations for advanced imaging and MSK services when member is enrolled in eviCore.
Provider should check Moda Health’s utilization management page for program and code lists.

Prior Authorization

Specialty drug prior authorization

Prior authorization for select specialty drugs and self-injectable medications is obtained through Magellan RX Management for fully insured groups; prior authorization for self-injectables under the Moda Pharmacy benefit is obtained via Moda Pharmacy Customer Service.

Magellan RX Management portal: https://specialtydrug.magellanprovider.com for many specialty drug PAs.
Self-injectable medications: obtain PA via Moda Pharmacy benefit (Pharmacy Customer Service 1‑888‑361‑1610).

Documentation Required

Clinical trials review

Clinical trial participation is reviewed by Moda Health; trial documentation (trial number, chart notes, protocol, signed consent) should be submitted to the Medical Director. Prior authorization is not required for trial participation but medical necessity will be reviewed with claim submission.

Send trial number, chart notes, protocol and signed consent to the Medical Director for review.
PA not required for clinical trial participation; review occurs at claim submission for medical necessity and coding.

Prior Authorization

DME prior authorization threshold

DME requests of $500 or more require prior authorization or may be reviewed for medical necessity upon claim submission.

DME dollar threshold for PA: $500.

Denial Risk

Therapeutic drug monitoring rules

Therapeutic drug monitoring (urine drug testing) is reviewed for medical necessity at claim submission; limits of 12 presumptive and 12 definitive tests apply. Certain presumptive UDT codes (e.g., 0227U) are listed as Not Covered effective 1/1/2021.

UDT limits: 12 presumptive and 12 definitive tests (effective 6/1/16).
Presumptive UDT code 0227U: Not Covered effective 1/1/2021.

Documentation Required

Verification and submission channels

Verify whether prior authorization is required by logging into Benefit Tracker (EBTWeb) or by calling Moda Health customer service at 800‑592‑8283. For members in Texas, eligibility/benefit verification may be performed via ashlink.com.

Benefit Tracker (https://www.modahealth.com/EBTWeb) for PA/benefit verification.
Customer service: 800‑592‑8283.
Texas members: use www.ashlink.com for eligibility/benefit verification.

Prior Authorization

Autism/neurodevelopmental therapy authorization

Intensive outpatient rehabilitation for autism spectrum disorder and other neurodevelopmental conditions must be authorized by Moda Health; do not send these authorization requests to eviCore.

All requests for intensive outpatient therapy for ASD/neurodevelopmental conditions are reviewed by Moda Health.
Do NOT submit these authorizations to eviCore.

Billing Rule

Residential Mental Health code mapping

T2048 (residential code) is mapped to residential mental health codes H0010, H0017, H0018, and H0019 for psychiatric residential treatment of children and adults.

Code mapping: T2048 -> H0010, H0017, H0018, H0019.

Billing Rule

Residential Substance Use Disorder code cross-reference

T2048 is cross-referenced with residential substance use disorder codes H0011, H0012, H0013 and is also mapped to H0010, H0017, H0018, H0019; ASAM level references are included in the mapping.

Residential SUD cross-reference: T2048 <-> H0011, H0012, H0013 mapped to H0010, H0017, H0018, H0019.
ASAM referenced in mapping notes.

Prior Authorization

Authorization routing notes (behavioral health residential services)

Authorization routing details for behavioral health residential services reference the T2048 mappings and indicate routing for authorization as noted in the provider listings (authorization routing language present in the policy).

See T2048 mappings and associated instructions for authorization routing of residential behavioral health services.

Prior Authorization

Advanced imaging prior authorization

Advanced imaging authorizations (MRI, MRA, CT, CTA and other advanced imaging) are performed by eviCore at www.eviCore.com for groups/members enrolled in eviCore.

Use www.eviCore.com for advanced imaging prior authorization when member is enrolled in eviCore.
Check EBT for member enrollment.

Prior Authorization

Drug authorization routing

Requests for authorization of many drugs are routed to Magellan RX for fully insured groups and individuals; groups that are not on Magellan RX should contact Moda Pharmacy/HCS for authorization processing.

Magellan RX handles drug PAs for fully insured groups/individuals.
Other groups: contact Moda Pharmacy/HCS.

Prior Authorization

Drug prior authorization routing

Many specific drugs listed in the policy require prior authorization and requests are processed by Magellan RX for fully insured groups and individuals; other groups should contact Moda Pharmacy/HCS for authorization.

Multiple specialty drugs in the list require PA via Magellan RX for fully insured groups.
Contact Moda Pharmacy/HCS for non‑Magellan groups.

Prior Authorization

Procedure prior authorization routing

Certain procedures and codes (for example echocardiography, pain injections, and HCPCS G0330) require prior authorization and are routed to eviCore for groups enrolled in eviCore; check EBT for enrollment and vendor lists.

Echocardiography and cardiac advanced imaging: eviCore performs PAs for enrolled groups.
Pain injections and related codes are routed to eviCore for enrolled groups; note G0330 PA effective 4/4/2024.

Prior Authorization

Device and specialty therapy authorization

Medical devices (including cooling devices), continuous glucose monitors, ophthalmology drugs and certain specialty therapies require prior authorization and reference Moda Health Medical Necessity Criteria (MHMNC) or MCG guidelines; some devices (active cooling devices) are not covered.

Device and therapy PAs reference MHMNC or MCG guidance.
Active cooling devices (e.g., Game Ready) are not covered.

Documentation Required

Interventional pain authorization notes

Epidural, facet, medial branch blocks and sacroiliac (SI) joint injections are reviewed by eviCore for groups enrolled in the advanced imaging/cardiology program; CPT 64483 for SI injections is reviewed by Moda Health.

Pain injection PAs performed by eviCore for enrolled groups (check EBT for enrollment).
Exception: CPT 64483 (SI joint injection) is reviewed by Moda Health.

Prior Authorization

Hemophilia factors and other specialty drugs authorization routing

If a specialty drug is provided by the pharmacy, requests for authorization are reviewed by Magellan RX for fully insured groups and individuals; other groups should contact Moda Pharmacy/HCS for authorization.

Pharmacy‑provided specialty drugs: Magellan RX for fully insured groups.
Other groups: Moda Pharmacy/HCS.

Prior Authorization

Home Ventilator authorization

Home ventilator equipment codes listed in the policy require prior authorization; reviewers are to reference MCG A-0343 Oxygen Therapy guidance and route authorization through Moda Pharmacy/HCS for groups not using eviCore.

Home ventilator PA references MCG A-0343 Oxygen Therapy.
PA routing: Moda Pharmacy/HCS for groups not using eviCore.

Prior Authorization

Knee surgery authorization routing

Knee arthroscopy and other knee surgeries require medical necessity review for fully insured groups; for groups enrolled in eviCore MSK, prior authorization is obtained through eviCore (check EBT for enrollment).

Medical necessity review required for fully insured groups and individuals.
eviCore handles PA for knee surgeries for members enrolled in MSK program; check EBT for enrollment.

Prior Authorization

PET Scans prior authorization routing

Prior authorization for PET scans is performed by eviCore for groups/members enrolled in eviCore; groups that do not use eviCore obtain prior authorization through Moda Health/HCS.

eviCore: PA for PET scans when member enrolled.
Groups without eviCore: obtain PA through Moda Health/HCS.

Prior Authorization

Spine/MSK prior authorization routing

Spinal surgeries and related musculoskeletal procedures, including spinal cord stimulator services, require prior authorization through eviCore MSK for members enrolled in that program; otherwise obtain authorization through Moda Health/HCS.

eviCore MSK: obtain PA for spinal surgeries and SCS services for enrolled members.
Members not enrolled in eviCore: route PA via Moda Health/HCS.

Prior Authorization

Drug authorization routing

Many specialty drugs and biologics listed require prior authorization; Magellan RX processes authorization requests for fully insured groups and individuals while other groups should contact Moda Pharmacy/HCS.

Magellan RX: primary handler for specialty drug PAs for fully insured groups/individuals.
Non‑Magellan groups: contact Moda Pharmacy/HCS.

Prior Authorization

Medical Director review required

The rectal control system (CPT/HCPC A4563) requires review by the Medical Director prior to authorization.

Device A4563: Medical Director review required for authorization.

Prior Authorization

Wheelchairs and wheelchair accessories

Wheelchairs and wheelchair accessories reference MCG wheelchair criteria (MCG A-0353/A-0354) and require prior authorization through Moda Health/HCS or the delegated vendor listed in the policy.

Refer to MCG A-0353 and A-0354 for wheelchair accessory and manual/power wheelchair criteria.
Obtain authorization via Moda Health/HCS or delegated vendor as listed.

Prior Authorization

Spinal Cord Stimulator - eviCore routing

Spinal cord stimulator services for members enrolled in eviCore MSK require prior authorization through eviCore (eviCore has handled these authorizations since 4/1/2017).

eviCore MSK: PA required for spinal cord stimulator services for enrolled members.
Effective process in place since 4/1/2017.

Prior Authorization

Drug authorization routing (Magellan RX / Moda Pharmacy-HCS)

Many specialty drugs and biologics in this segment require prior authorization; for fully insured groups and individuals Magellan RX provides authorization processing while other groups should contact Moda Pharmacy/HCS. Some items reference Moda Health Medical Necessity Criteria (MHMNC) or MCG for clinical guidance.

Magellan RX processes PAs for many specialty drugs for fully insured groups/individuals.
Other groups: contact Moda Pharmacy/HCS.
Refer to MHMNC or MCG guidance where indicated for clinical criteria.

Prior Authorization

Transcatheter pacemaker component insertion/removal

Transcatheter insertion or removal of pacemaker components (effective 7/1/2023 codes 0795T–0800T) requires contacting eviCore for groups enrolled in eviCore; groups without eviCore must obtain prior authorization through Moda Health/HCS.

Codes effective 7/1/2023: 0795T, 0796T, 0797T, 0798T, 0799T, 0800T.
eviCore: contact for PA if group is enrolled; otherwise route PA via Moda Health/HCS.

Prior Authorization

Inpatient admission for drug administration - prior auth

Drug authorization must be obtained prior to requesting inpatient admission for drug administration (example: CAR‑T and other infusion therapies require drug authorization before requesting the inpatient admission).

Obtain drug authorization before requesting inpatient admission for drug administration.
Examples noted include CAR‑T and other infusion therapies.

Definitions and referenced programs

Urgent/Emergent Admission — notification

Notification timeframeAll urgent/emergent inpatient admissions require notification to Moda Health within 48 hours of admission

ScopeApplies to all urgent/emergent admissions to an inpatient facility

Follow-upNotification should be made to Moda Health as specified in provider channels

Inpatient Elective Admission — definition and PA requirement

DefinitionInpatient elective admissions must meet the definition of an ‘emergency medical condition’ and require prior authorization for all inpatient elective admissions to an acute care facility

Prior authorization requirementPrior authorization is required prior to elective inpatient admission

Related facility typesRequirement complements PA rules for skilled nursing, inpatient rehab, and long term acute care facilities

Clinical Trials — documentation for Medical Director review

Documentation for reviewSend trial number, chart notes, protocol, and signed consent to the Medical Director for review

Prior authorization stancePrior authorization is not required for clinical trial participation but participation will be reviewed with claim submission for medical necessity

Review contactClinical trial documentation should be submitted to the Medical Director as part of medical necessity review

ASAM — referenced in residential SUD mapping

ASAM reference in mappingsASAM is referenced in residential SUD and mental health code mapping (T2048 cross-references)

ContextMappings link T2048 with residential mental health and residential SUD codes and note ASAM level mapping

UseASAM referenced to align residential service coding between mental health and SUD mappings

T2048 mapping — Residential Mental Health

T2048 mappingT2048 mapped to Residential Mental Health and cross-referenced to H0010, H0017, H0018, H0019

Associated codesMapping indicates T2048 equivalency to H0010/H0017/H0018/H0019 for psychiatric residential treatment of children and adults

Guidance sourceMapped references appear in Moda Health MHMNC guidance for psychiatric residential treatment

Moda Health Medical Necessity Criteria (MHMNC) or MCG — guideline references

Primary guideline referencesModa Health Medical Necessity Criteria (MHMNC) or MCG Guidelines are used for clinical reviews and authorization decisions

ApplicationMHMNC/MCG referenced across multiple drug, device, and procedural entries to determine medical necessity

Where notedSee specific MHMNC or MCG guideline IDs listed with procedures (e.g., stereotactic radiosurgery, joint surgery) for criteria

eviCore — advanced imaging and cardiology PA vendor

eviCore roleeviCore performs prior authorizations for advanced imaging and cardiology services (authorizations obtained via www.eviCore.com)

Program listsLists of programs and procedure codes requiring eviCore authorization are maintained on modahealth.com and eviCore websites

Cardiology scopeeviCore handles cardiology diagnostic procedures, pacemakers, angiograms, and related imaging for enrolled groups

Magellan RX — authorization vendor

Magellan RX roleMagellan RX provides authorization services for many specialty drugs for fully insured groups and individuals

Alternate routingOther groups and individuals should contact Moda Pharmacy/HCS for drug authorization

ExamplesMagellan RX handles authorizations for listed drugs (see MHMNC entries) while Moda Pharmacy/HCS supports other client groups

eviCore — advanced imaging/cardiology and interventional pain vendor

eviCore functions (re-iterated)eviCore performs prior authorizations for advanced imaging, echocardiography, cardiac imaging, and interventional pain services for enrolled groups

Enrollment checkCheck EBT for member enrollment in eviCore programs to determine routing

Effective dateseviCore assumed some authorizations as of 4/1/2017 (cardiology/advanced imaging) and for interventional pain lists

Moda Pharmacy/HCS — internal pharmacy authorization/review

Moda Pharmacy / HCS roleModa Pharmacy/HCS reviews authorizations for drugs and pharmacy-provided therapies for groups not handled by Magellan RX

Pharmacy RX notePharmacy RX may review certain self-injectables or Oregon commercial fully insured drugs as specified

Interaction with Magellan RXWhere Magellan RX is the vendor for fully insured groups, Moda Pharmacy/HCS handles authorizations for other groups

eviCore — reference

eviCore reference (general)eviCore is the external authorization vendor for members enrolled in eviCore programs (see provider website/EBT for enrollment)

MSK and interventional paineviCore MSK handles joint, spine, and interventional pain prior authorizations for enrolled members

Provider guidanceProviders should check eviCore and Moda Health resources for procedure lists and PA instructions

Magellan RX / Moda Pharmacy/HCS — drug PA handling split

Drug PA handling by group typeMagellan RX processes drug prior authorizations for fully insured groups and individuals; other groups contact Moda Pharmacy/HCS

ScopeApplies to many specialty drugs and biologics listed in MHMNC entries

Provider actionCheck the member’s group/vendor routing (Magellan RX vs Moda Pharmacy/HCS) before submitting PA requests

eviCore — reference

eviCore reference (imaging/MSK)eviCore handles prior authorization for PET, SPECT, and certain MSK/spinal procedures for enrolled groups; groups without eviCore obtain PA via Moda Health/HCS

Routing instructionCheck EBT for member enrollment to determine whether to route PA to eviCore or Moda Health/HCS

Guideline linkageRefer to MHMNC/MCG criteria and eviCore code lists for specific procedure authorization requirements

Magellan RX — drug authorization vendor

Magellan RX (drug authorization vendor) — repeatedMagellan RX provides authorization for many specialty drugs for fully insured members; other groups contact Moda Pharmacy/HCS

Integration with MHMNCDrug requests reference the applicable MHMNC guideline for each drug when routed to Magellan RX

ExamplesNumerous J‑codes listed in the document are routed to Magellan RX for PA processing

eviCore MSK — MSK prior authorization program/vendor

eviCore MSK programeviCore MSK is the program/vendor through which prior authorizations for specified musculoskeletal and interventional pain procedures are obtained for enrolled members (check EBT)

Scope examplesHip and knee replacements, spine surgeries, and spinal cord stimulator services are included under eviCore MSK lists for enrolled members

Enrollment checkProviders should verify member enrollment in eviCore MSK via EBT before submitting PA requests

Magellan RX — vendor for drug PA (fully insured groups)

Magellan RX responsibility for fully insured groupsMagellan RX is responsible for processing drug prior authorization requests for fully insured groups and individuals; other groups contact Moda Pharmacy/HCS

Associated guidanceRefer to the applicable MHMNC for each drug when submitting PA requests to Magellan RX

ExamplesMultiple specialty drug entries and J‑codes in the document note Magellan RX as the PA handler for fully insured members

OpenPayer

Prior authorization and utilization management procedures

Coverage criteria and authorization rules

Codes and code groups referenced

What providers must do (authorization routes, documentation, contacts)

Definitions and referenced programs