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Prior authorizations and referrals

To help understand what services need prior authorization, Moda Health provides these prior authorization lists.


New! Submit your prior authorization request electronically

Please refer to these documents to help you determine if your patient needs a prior authorization:

Prior authorizations for Pharmacy

For help with prior authorizations for pharmacy, see the Pharmacy Support Page.

Prior authorizations for Behavioral Health

For help with prior authorizations for Behavioral Health procedures, see the Behavioral Health Support Page.

Support by type of procedure or location

Medical Necessity Criteria

Please refer to our Medical Necessity Criteria Support Page a complete list of medical necessity criteria.

Please refer to our Injectables/Infusion/Specialty Page for a complete list of medications requiring prior authorization and their criteria.

Prior authorization contacts

For help with referrals most procedures including Referrals, Inpatient Elective Procedures, Outpatient Selected Elective Procedures, Skilled Nursing Facility Long-Term Acute Care, Inpatient Rehabilitation, Home Health/Home Infusion, Hospice – Initial Evaluation and Service, Durable Medical Equipment (DME) and Transplants contact our Healthcare Service Team.

Phone: 888-474-8540 or 800-258-2037
Fax: 800-522-7004 

Chemical Dependency and Mental Health authorizations

Phone: 855-294-1665
Fax: 503-670-8349

Expedited requests

If you need help with getting a request expedited, please call Healthcare Services at 888-474-8540 or 800-258-2037 or fax at 503-243-5105.

An expedited request is completed within 72 hours of receipt. Submitting an expedited request means that you are attesting that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.

Prior authorization data history

2023

2022

 

Questions?

Medical Customer Service is at 844-931-1779.

We're available 6:00 a.m. to 6:00 p.m. Monday through Friday, 9:00 a.m. to Noon Saturday, Sunday, and Holidays (Central Time).

See more contact details

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