Authorizations and referrals

If you are an in-network provider, most authorizations and referrals can be completed online using the Moda Health Benefit Tracker. For out-of-network providers, call us at 844-746-0540 for assistance.

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Ensuring your patients’ care is covered

Managing authorizations and referrals can be complex, with different criteria for various procedures, services and pharmaceuticals. We’ve put together guidelines based on your patients’ conditions and needs.

Number 1 circled representing Step 1.

Step 1: Gather what you’ll need for each authorization request

Each prior authorization request should include:

  • All pertinent member information (name, ID number, group number and member's date of birth)
  • PCP information (name, TIN, phone, fax and contact name)
  • Facility details (name and TIN of the facility where the procedure is to be performed)
  • Relevant dates (date of the procedure and/or date of admission)
  • Specialist information (surgeon's or specialist's full name and TIN)
  • CPT and diagnosis codes (required)
  • Length of stay (indicate if inpatient)
  • Chart notes (any additional information that can help expedite a request)

Number 2 circled representing Step 2.

Step 2: Review criteria

As part of delivering the best care to your patients, Moda Health develops or adopts medical necessity criteria for certain services. These services may include new technologies, medications, behavioral health treatments and other procedures that don’t already have established clinical guidelines.

Our criteria are based on published scientific evidence and guidance from regulatory agencies and professional organizations. Each set of criteria is reviewed by a medical director, licensed psychiatrist, or an appropriate external specialist. The following documents help determine authorization requirements and where to submit requests for specific procedures and services:

Certain services, procedures and pharmaceuticals have particular requirements and criteria, based on complexity, cost or utilization. Use the pages below to determine those specifics:

Pre-authorization is required for all inpatient admissions

For inpatient services, ensure the following criteria are met. Failure to obtain prior authorization results in a penalty to the member of 50% up to a maximum deduction of $2,500 per occurrence.

  1. Determine coverage through Moda Health Medical Necessity Criteria, MCG guidelines or CMS guidelines.
  2. Before requesting authorization, verify member's eligibility and benefits.
  3. Confirm that the requested provider or facility is in-network.
  4. Verify member network availability and any contract specific pre-authorization requirements.

Note that pre-authorization of a service or procedure does not guarantee payment.

Number 3 circled representing Step 3.

Step 3: Request prior authorization

For urgent or emergent hospital admissions, contact Moda Health customer service at 844-746-0540 within 48 hours to request prior authorization.

What if authorization isn’t approved?

If a prior authorization is denied, we’re here to guide you through next steps. Contact us at 844-746-0540 with questions or if you need help with specific treatments, like intensive outpatient rehabilitation, autism spectrum disorder or neurodevelopmental conditions.

Your prior authorization team

Please select the service phone number based on your patient’s Moda Health plan and type of service and let us know if you need your request expedited.

Moda Health (general plan) support

OEBB Moda Health plan support

PEBB Moda Health plan support

We’re here to help

Our team of experts would be happy to answer your questions and help you find what you need. Use the customer service number on the back of your patient's Moda Health ID card to reach us.