Claim edits policy
In a partnership with Prime Therapeutics Management LLC, 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 do this by reviewing claims for appropriate frequency, correct units, and eligible diagnosis codes. This program is limited to claims reviewed and to medications injected and/or infused in a professional office, home, or outpatient setting.
This program is limited to 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 medications in the list below. Prior authorization criteria do not apply for these medications; however, please review the criteria below for specific covered diagnosis codes and dosing limits for each medication. If the services billed do not meet the criteria, the claims will be subject to review and potentially disallowed.
- Azedra® (iobenguane I-131)
- Bortezomib
- Cinvanti® (aprepitant)
- Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
- Fulvestrant: Faslodex®; Fulvestrant ?
- Gemcitabine: Gemzar®; Gemcitabine
- Hicon® (Sodium Iodide I - 131)
- Leuprolide Suspension: Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®, Camcevi™, Leuprolide Acetate Depot Ψ
- Lutathera® (lutetium Lu 177 dotatate)
- Metastron™ (Strontium-89 Chloride)
- Pluvicto® (lutetium Lu 177 vipivotide tetraxetan)
- Quadramet® (Samarium Sm 153 Lexidronam)
- Scenesse® (afamelanotide)
- Trelstar® (triptorelin)
- Xofigo® (radium Ra 223 dichloride)
- Zevalin® (ibritumomab tiuxetan)
- Zoladex® (goserelin acetate)
As new medications are added to the program, provider notifications will be sent to provider practices and updates will be posted to this page.
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