Noridian, Palmetto, and the MolDx Joint Operating Agreement: Key Words Changed

The MolDx program, operated by Palmetto GBA MAC, provides uniforms policies for about 30 states, being Medicare MAC Jurisdictions E-F (under Noridian), JM-JJ under Palmetto, and three more jurisdictions under WPS MAC (two) and CGS MAC (one).  

In theory, they use the same edits based on the MolDx Master Edit File (MEF) and uniform LCDs and articles.  However, the lab community was started in May when Noridian MAC began deleted LCDs that had been finalized in other parts of the MolDx system (story here).

This year, the Jurisdiction E MAC (CA, NV, HI)  is under recompete (story here).  The statement of work for J-E specifically requires that the MAC have a joint operating agreement with MolDx.  To see the statement of work for J-E, go to the RFP website here, click on Government Files tab, then scroll to bottom for Government Files section, set for "50" files to display, and seek Statement of Work.  (I've also put a cloud copy here.)  

Take Home Lesson:  Term "Provided By" Revised to "In Cooperation With"

Note that the federal contract, vintage 2019, shown at bottom states that MAC will implement guidelines "provided by" the MolDx contractor (e.g. MolDx).   

Here's a discrepancy worth noting.  Noridian's current website in which it describes MolDx, has revised the 2019 wording read as of April 2020, Noridian shall implement guidelines "in cooperation with" the MolDx contractor (here).   Noridian's MolDx webpage basically cuts/pastes for the public the same text as in the federal RFP SOW for its MAC.

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I've clipped the 2019 vintage federal JOA as in the MAC rebid document below.  

The text below describes that Noridian and MolDx shall have a JOA; I've requested the actual text of the JOA from Noridian via FOIA, and Noridian is conferring with SF Regional Office before releasing it.

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C.1.1.1  Joint Operating Agreement: 

Moldx Program Maintainer

The MolDX Program was developed by Palmetto GBA in 2011 to identify and establish coverage and reimbursement for molecular diagnostic tests. This program performs the following functions.

•                     Facilitates detailed and unique identification through registration of molecular diagnostic tests to facilitate claims processing and to track utilization.

•                     Establishes clinical utility expectations.

•                     Completes technical assessments of published test data to determine clinical utility and coverage.

•                     Establishes reimbursement.

It (MolDX) remains intact and active. The Program Maintainer will continue to administer the Program and all its information. 

The Contractor [for J-E MAC] shall enter into a JOA with the MolDx Program Maintainer for what responsibilities are that of the maintainer and the contractor, how they will interact, but not limited to all activities surrounding MolDx.

Responsibilities

MolDx Program Maintainer

•                     Determinations regarding coverage

•                     Pricing

•                     Coordination with McKesson to establish a unique identification numbers

•                     Coordination and communication with Noridian on all claims processing guidelines

MolDx Jurisdiction Claims Administrator

•                     Implement MolDX guidelines provided by Palmetto GBA

•                     Process claims with Palmetto GBA guidelines

•                     Appeals/Reopenings for claims processing

Providers

•                     Continue to send new test documentation to Palmetto GBA

•                     Send Medicare claims to Noridian after the unique identifiers have been assigned

•                     Send policy and coverage questions to Palmetto at moldx@palmettogba.com

•                     Contact the Noridian Provider Contact Center with claims processing questions

•                     Submit Reopening/Appeals requests to Noridian