Referral and authorizations FAQs

What does the eligibility disclaimer mean?

If the memberís plan is "fully insured", as described in the Member Handbook, prior authorizations for medical necessity shall be binding if obtained no more than 30 calendar days prior to the date the service is provided, and eligibility shall be binding for 5 business days from the date of the authorization.

Moda Health will guarantee member eligibility for five business days following the date the authorization is approved. Eligibility must be in effect for services performed after this five day period. Moda Health also guarantees benefits for 30 days from the date the authorization is approved. Services after this 30-day period are subject to benefits that are in place at the time the services are rendered.

Binding provisions do not apply in the case of fraud or misrepresentation.

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What is the difference between a referral request and an authorization request?

A referral request is a request by a primary care physician (PCP) for Moda Health to approve coverage for a patient to see a specialist. An authorization request is a request for approval of coverage for a service based on review of the member's plan benefits or review of the service for medical necessity.

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What is the direct line for authorizations and referrals?

Moda Health has dedicated telephone lines for healthcare professionals who would like to process requests for referrals or service authorizations. Please call us at 503-243-4496 or toll-free at 800-258-2037.

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If a procedure or service is excluded from a member's plan benefits, can we obtain authorization if we are able to establish medical necessity?

If a procedure or service is excluded from the member's plan, benefits will not be available even if medical necessity is established. Please refer to the member's plan benefits for limitations and exclusions.

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How do I set up a referral?

Referrals can be set up online through Enterprise Benefit Tracker (EBT) or by calling in at 503-243-4496 or toll-free at 800-258-2037. Included in the referral set up is the specialist name, number of visits, dates of service, outpatient diagnostic tests, office treatment, etc.

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Where can I view my referrals for Moda Health members?

Referrals for Moda Health members can be viewed online through Enterprise Benefit Tracker (EBT).

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How do I extend a referral?

To extend the dates or increase the number of visits on an expired referral, the patient's current primary care physician must submit the referral extension request to Moda Health by contacting the medical intake unit at 503-243-4496 or toll-free at 800-258-2037.

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How do I determine if a procedure/service requires a prior authorization?

Please refer to the Referral and Authorization Guidelinesreferral and authorization guidelinereferral and authorization guideline, complete the prior authorization form and fax in the completed form to 503-243-5105. Or call medical intake unit at 503-243-4496 or toll-free at 800-258-2037.

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Do members need a referral for routine vision services, annual women's exams or maternity care?

No, they can self refer to an optometrist for vision services or to an OB/GYN for routine annual women's exam or maternity care. Benefits may be limited for these services. Contact Moda Health Customer Service at 503-243-3962 or toll-free at 877-605-3229 for benefits.

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If an OB/GYN finds something during a routine exam that requires additional testing or treatment, can he or she request an authorization without going through the primary care physician (PCP)?

Yes, if an OB/GYN determines that further medical investigation is needed relating to an obstetric or gynecologic condition, he or she can contact Moda Health without going through the PCP for an authorization. Nevertheless, the PCP should be informed of the gynecologic condition discovered during the exam. If the medical condition is not related to obstetrics or gynecology, then the PCP will have to initiate any follow-up referrals or authorizations. Some groups have exceptions, so please refer to the Referral and Authorization Guidelinesreferral and authorization guidelinereferral and authorization guideline.

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Do diagnostic imaging procedures such as CAT scans, MRIs, SPECT and specialty imaging studies require an authorization?

It depends on the member's group. Some groups that require prior authorization of advanced imaging services utilize AIM Specialty HealthSM while other groups go through Moda Health. Please contact our customer service department at 503-243-3962 or toll-free at 877-664-4762 for group specific information.

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What is the Moda Health on-call/call-share policy?

Call share is considered coverage arrangement you have made among Participating Providers to ensure covered services when you are unavailable due to vacation, illness and/or after hours.

Moda Health will honor an existing referral or authorization to a specialist without going back through the PCP for on-call and call-share situations. The referral or authorization will be valid for the specialist's call-share partner(s). NOTE: Call-share specialists must be in-network with the patient's plan for the patient to receive the higher level of benefits.

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Are referrals or authorizations required for mental health and chemical dependency treatment?

Referrals are not required for mental health and chemical dependency treatment. Certain plans do require authorization for treatment. Please contact Moda Health Customer Service at 503-243-3962 or toll-free at 877-605-3229 to determine if an authorization is required and/or to obtain benefits.

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