Forms, policies and manuals

Administrative forms

• Electronic Funds Transfer / Electronic Remittance Advice Enrollment Form - Allows for electronic transfer of funds to a bank account in lieu of paper checks
• Medical/Vision Claim Form - A fillable PDF for a claim. You may want to consider electronic claim submission instead.
• Provider Data Form - Data about your office for our files
• Medical Provider Nomination Form - Nominate a provider for our panel. Please consider reviewing our panel needs first
• Provider Refund Submission - Submit a refund for over payment on a claim
• Locum Tenens Form
• Hospital Based Provider Enrollment Form

General forms

• Advance Directive - A patient’s wishes for their care, should they be too ill or hurt to express it themselves
• Coordination of benefits form - Allows a partner’s or spouse’s coverage to help cover a procedure for a patient

Authorization forms

• Member authorization for Moda Health release of PHI
• Member authorization for provider release of PHI to Moda Health
  
  
• Referral/Authorization - referral or authorization form (Moda Health)

Behavioral health forms

• Behavioral Health Authorization Request Form
• Moda Health Behavioral Health Specialties form
• Case management referral form

Manuals and policies

• Clinical Editing Policy Information
• Electronic remittance explanation codes
• No Surprises Act - read about our policies to support the No Surprises Act
• Patient rights and responsibilities - guide for our members/patients rights and responsibilities
• Provider Manual (Requires login to Benefit Tracker)
• Secure Storage and Transport of PHI Policy
• Reimbursement Policy Manual - access our guide to our reimbursement policies