Value-based payment resources

Program guidelines and structure

Intercambio de Datos de Proveedores (EDP) de Moda Health

Moda acepta datos clínicos mediante envío automático de datos SFTP. Contacta con ValueBasedDataSharing@modahealth.com para empezar

Los proveedores con más de 2.000 miembros atribuidos a Moda a fecha de 15 de noviembre de 2025 deben enviar correctamente los datos a través de PDE antes del 15 de marzo de 2027 para ser elegibles para CUALQUIER incentivo de pago basado en valor. El proceso de puesta en marcha suele durar entre 1 y 3 meses, por lo que los proveedores deberían planificarlo (no esperes hasta marzo de 2027 para empezar). Requisitos actuales de archivos de datos de EDP.

Directrices para la presentación de cartas clínicas de proveedores

Providing responsible party contact information to Moda

Email ProviderReports@modahealth.com and include:

  • Contact person's name
  • Contact person's role (ex: clinical manager, medical director)
  • Contact person's email address
  • Organization's tax ID number

How to make changes to patient attribution

Because Oregon law requires Moda to attribute all members to a PCP, some members may be attributed to your clinic that have not yet established care. Review Moda Health’s attribution policy for instructions on how to request reassignment of a member.

Provider guidance on attribution

From time to time, providers request that certain members either be added or removed from their patient panel. This document explains some of the issues surrounding attribution, such as how members might come to be attributed to providers, what to do when those attributions conflict with provider or member experience, and how Moda will respond to requests to change attribution data.

Because Moda prioritizes member PCP selection in our attribution algorithms, and because certain Moda lines of business have regulatory requirements to assign all members to a PCP, it is possible that some members may be attributed to clinics where they have never had a visit. If a PCP has notified Moda that they are accepting new patients, then Moda has no choice but to honor a member request to be assigned to that PCP. Therefore, if the PCP subsequently requests that the member be removed from their panel because of not yet having established care, such requests will not automatically be honored. See below for a description of the criteria and process for a provider to follow to remove an attributed member from their panel.

All provider inquiries related to attributions should be directed to providerreports@modahealth.com

Attribution overview

Moda follows the attribution guidelines established in Oregon Senate Bill 1529, with additional clarifications as described below. At a high level, attribution is handled as follows:

  1. Member choice is prioritized. If a member notifies Moda of their PCP selection, that selection takes priority. Such priority is not permanent (see below).
  2. In the absence of member choice, Moda uses 24 months of claims history to attribute members. Members will be attributed to the PCP they have seen most often in the last 24 months, and if there is a tie, the member will be attributed to the PCP seen most recently.
  3. If required by Oregon SB1529, or at the request of the employer group, if there is no member selection and no history of PCP visits Moda will assign the member to a nearby PCP, taking into account the PCP's open/closed practice status and network participation. Note that Oregon SB1529 does not require this 'geographic' attribution for ASO groups or members who live outside of Oregon.
  4. If Moda determines that subsequent to a member PCP selection, there is convincing evidence that the member has chosen a new PCP but failed to notify Moda, then Moda will change the member's PCP in our system, notifying the member and provider. 'Convincing evidence' means that the member has had two or more visits in a row with a PCP that is different than the one selected, and both visits occurred after the date that the member's PCP was last changed.
  5. Moda will not attribute members to providers who are not credentialled as PCPs.
  6. Moda will not use claims history or geography to attribute members to OB/GYNs, given the propensity for some members to use separate providers for OB/GYN and primary care services. However, a member is free to select an OB/GYN as their primary care provider if desired (if the OB/GYN provider is credentialled as a PCP - most are not).
  7. Male members will not be attributed to women's health clinics, and female members will not be attributed to men's health clinics.
  8. Moda will not attribute members to urgent care providers or out-of-network providers.
  9. Members under age 26 may be attributed to a pediatrician based on claims history, but no member age 18 or older will be geographically attributed to a pediatrician.
  10. Additional details on member attribution can be found in Moda's complete attribution policy, available to providers upon request.

Criteria for reassigning a member based on provider request

Moda will remove a member from a provider's attributed list if requested by the attributed PCP, only in the seven situations described below. All reassignments will be effective as of the date that Moda was notified. Reassignments will not be made retroactive to prior date (e.g. a provider should not ask Moda in December to remove a member from their panel as of the previous January). The reason for this is that if the member is being removed from one provider's panel, that means that member will be added to another provider's panel, and Moda must notify the new provider timely. That notification cannot happen retroactively.

Moda will reassign members based on a provider's request only if:

  1. ALL THREE of the following are true:
    1. The provider notifies Moda that the member has never established care
    2. The member has not had a visit with the provider in the past 24 months
    3. The provider is configured as 'not accepting new patients' in our Facets system. If the provider is currently configured as accepting new patients, the provider will need to contact providerupdates@modahealth.com and request that this be changed.
  2. BOTH of the following are true:
    1. The assigned provider notifies Moda via providerreports@modahealth.com that the member has indicated (e.g. during outreach calls) that they have established care elsewhere.
    2. The member's most recent PCP claim is with a provider other than the assigned PCP. Note that reassignment to the new PCP is automatic if the member's last TWO visits are with a PCP that is not the assigned PCP; this does not require any action by the provider.
  3. Member is age 18 or older and the provider is a pediatrician.
  4. Member is male and the provider is a women's healthcare clinic, or vice versa.
  5. The provider clinic has permanently closed.
  6. BOTH of the following are true:
    1. The provider has notified Moda that the clinic has downsized staff and no longer has the capacity to serve their entire patient panel
    2. The count of members requested to be reassigned are in direct proportion to the capacity reduction at the clinic. For example, if the clinic transitions from three providers to two providers, Moda will reassign 1/3 of the total panel if requested, but will not reassign only a handful of specific members. This is to prevent the opportunity for 'gaming' of quality metric incentives by excluding members with care gaps.
  7. BOTH of the following are true:
    1. The provider notifies Moda that the member has indicated they have moved out of the area and will not be returning for care.
    2. The member has provided their new address to Moda.

Questions? We're here to help!

For general questions regarding these programs, please email ProviderReports@modahealth.com.
For questions specific to submitting clinical data via the online form, please email SummaryData@modahealth.com.