Authorization and referrals for services and procedures

At Moda Health, we’re committed to supporting you in delivering the best care to your patients. For certain complex, high-cost or highly utilized services on the prior authorization list, we develop or adopt medical necessity criteria to ensure appropriate care.

Services include new technologies, medications, behavioral health treatments and other services that may or may not have established clinical guidelines. We base our criteria on published scientific evidence and guidance from relevant regulatory bodies. To ensure accuracy and appropriateness, each set of criteria is carefully reviewed by our medical director, licensed psychiatrist or an external specialist.

If you are an in-network provider, most authorizations, approvals and referrals can be completed online using the Moda Health Benefit Tracker. For out-of-network providers, call us at the number on the back of your patient's Moda Health medical insurance ID card.

Advanced imaging and musculoskeletal services

For certain services and procedures, we partner with EviCore, a specialty benefits management company, who offers the latest evidence-based medical guidelines. Prior authorization helps us keep up with changing information, requirements and citations for services like CT/PET scans, MRIs, chiropractic, acupuncture, massage and physical therapy. Specific guidelines for each procedure can be found on the EviCore website. Please follow onscreen instructions to find the most recent documentation.

Cardiology
Joint surgery
Radiology
Pain management
Spine surgery
Therapy
Genetic testing

Learn more at eviCore(opens in new tab)

Requesting prior authorization advanced imaging and musculoskeletal services

For the fastest and most efficient prior authorization process, submit your requests online. EviCore provides several program tools to ensure a smooth authorization process:

Training

Ask your Moda Health medical provider relations representative to arrange a training session for you and your staff with EviCore’s team. Call at 877-605-3229 or email medical@modahealth.com. TTY users, please dial 711.

Peer review

You can request a consult with a peer reviewer by completing the EviCore online form. Once submitted, EviCore will contact you to schedule an appointment.

Clinical worksheets

Consider using EviCore’s clinical worksheets to ensure you’re submitting the right information according to their guidelines.

Log in to Benefit Tracker

Most authorizations, approvals and referrals can be completed online through Benefit Tracker, for in-network providers. For out-of-network providers, call us at 844-746-0540 for assistance.

Surgical care services

At Moda Health, we use evidence-based MCG® guidelines to promote quality care, patient safety and the best use of healthcare resources. MCG guidelines are built on rigorous evidence, reviewed annually by doctors and nurses who cite over 15,000 unique references. MCG validates recommendations using real-world data from large U.S. populations, ensuring that results are achievable in real-life situations. Procedures using these guidelines include:

Inpatient and outpatient surgeries

Hospital stays, including medical and behavioral health admissions

Care in skilled nursing, acute rehab, and long-term acute care facilities

Outpatient therapies, acupuncture and durable medical equipment

Requesting prior authorization for surgical care services

For urgent or emergent hospital admissions, please contact Moda Health at (800) 592-8283.

For inpatient admissions, you must first confirm the following:

Step 1: Verify member's eligibility, network availability and benefits by logging in to BenefitTracker.
Step 2: Verify that the requested provider or facility is in-network using Find Care.
Step 3: Determine coverage using Moda Health Medical Necessity Criteria, MCG guidelines or CMS guidelines.
Step 4: Verify any contract specific pre-authorization requirements (e.g., eviCore or Prime Therapeutics) through BenefitTracker.

Once this information is verified, you can submit your prior authorization request electronically through Benefit Tracker. Your request must include:

Member information, including name, date of birth, ID #, and group #
Provider information, including name, TIN, phone, fax and contact name
Facility information where procedure is to be performed, including name and TIN
The date of the procedure or date of admission
Surgeon's or specialist's full name and TIN
CPT and diagnosis codes
Length of stay (indicate if inpatient)
Chart notes

Pre-authorization is required for all inpatient admissions and members may not be balance billed. Failure to obtain prior authorization results in a penalty to the member of 50% up to a maximum deduction of $2,500 per occurrence. It’s also important to note that pre-authorization of a service or procedure does not guarantee payment.

For details on how to submit your application in Benefit Tracker, review the authorization application how-to guide.

Medical necessity criteria

We base our medical necessity criteria on several sources:

MCG^®- Moda Health utilizes the evidence-based MCG® for:
- Inpatient and outpatient surgeries
- Initial and ongoing goal length of stay for admissions to:
  - Inpatient facilities, including medical and behavioral health admissions
  - Skilled nursing facilities
  - Acute in-patient rehabilitation
  - Long-term acute care facilities
- Outpatient therapies
- Durable medical equipment
eviCore- for Advanced Imaging, Cardiology and Musculoskeletal procedures and services

Complete list of our Medical Necessity Criteria for Medications and Procedures (for Commercial Plans)

Reference tools

These resources can help you determine if your patient needs a prior authorization.

Questions? We’re here to help

Please select the service phone number based on your patient’s Moda Health plan and type of service.