Referral and authorization guidelines

To help you understand what services need prior authorization, are always not covered or not medically necessary, we're updating our prior authorization lists.

The following lists cover our lines of business. Because some services are considered investigational, cosmetic, or always not medically necessary, we are including a separate list of the services that are always not covered.

Effective January 1, 2017 for all in-network individual, ASO, small, and large group plans, Moda will deny services if required prior authorization is not obtained prior to rendering the service. If a prior authorization is not obtained for in-network services, Moda will deny charges as provider responsibility.

Medicare

Group/Individual

Prior authorization contact information
Type of Service Phone Number OEBB Phone Number PEBB Phone Number
Inpatient Elective Procedures,

Outpatient Selected Elective Procedures,

Skilled Nursing Facility Long-Term Acute Care,

Inpatient Rehabilitation,

Home Health/Home Infusion,

Hospice – Initial Evaluation and Service,

Transplants
Local:
503-265-2940

Toll-free:
888-474-8540 or 800-258-2037

Fax:
503-243-5105
Local:
503-234-4496

Toll-free:
800-258-2037
PEBB Customer Service:

Toll-free:
844-776-1593
Chemical Dependency and Mental Health Toll-free:
855-294-1665

Fax:
503-670-8349
OEBB Authorization Number:

Toll-free:
855-294-1665

Fax:
503-670-8349
PEBB Customer Service:

Toll-free:
800-799-9391
Expedited Requests Local:
503-265-2940

Toll-free:
888-474-8540 or 800-258-2037

Fax:
503-243-5105
OEBB Authorization Number:

Local:
503-234-4496

Toll-free:
800-258-2037
PEBB Customer Service:

Toll-free:
844-776-1593
Referrals for Managed Care/Point of Service Groups Local:
503-265-2940

Toll-free:
888-474-8540 or 800-258-2037

Fax:
503-243-5105
Not applicable Not applicable
Advanced Imaging and Musculoskeletal Services

Authorizations for advanced imaging studies and musculoskeletal services are obtained through eviCore healthcare

Log in to eviCore's Provider Portal at
www.evicore.com

Phone: 844-303-8451

For more information and codes requiring authorization go to www.evicore.com

Specialty Infusion/Injectable Drugs Authorizations for selected Intravenous infusion or injectable drugs are obtained through Magellan Rx.

Login to Magellan Rx Provider Portal at www.mcg.com.
Instructions for requesting prior authorization
Urgent/Emergent Hospital Admissions Contact Moda Health within 48 hours of all urgent/emergent admission.
Elective inpatient procedures
  1. Pre-authorization is required for all inpatient admissions. Failure to obtain authorization may result in non-payment of claim and provider liability. Members may not be balance billed.
  2. Before requesting authorization, verify member's eligibility and benefits through online access in EBT.
  3. Verify that the requested provider or facility is in-network.
  4. Moda Health Medical Necessity Criteria, MCG guidelines, or CMS guidelines may be used for coverage determination.
  5. Verify member network availability and any contract specific pre-authorization requirements through EBT.
  6. Pre-authorization of a service or procedure does not guarantee payment.

Questions?
We're here to help! If you have questions, please call our Customer Service team at 503-243-3962 or toll-free at 877-605-3229. Or, email us at

Referral and authorization guidelines

Care coordination

Care coordination registered nurses work directly with facilities and providers to facilitate preauthorization of scheduled procedures, inpatient stays, and follow-up care as needed for members during urgent or emergent admissions. During the time a member is receiving care or is hospitalized, care coordination nurses may refer them to a case management nurse if they require additional assistance and coordination for complex or catastrophic conditions.

The hospital calls Moda Health to notify us of all urgent/emergent hospital admissions within 48 hours, or as soon as possible.

Inpatient admission

Preauthorization is required for all non-emergent inpatient admissions, including acute care hospitals, inpatient rehabilitation and skilled nursing facilities. If the member is experiencing a serious illness or injury and requires post-hospital follow-up such as home-health or outpatient therapy, Moda Health care coordination nurses will work with the facility to coordinate discharge needs.

To obtain the required preauthorization, please call us at 503-243-4496 or toll-free 800-258-2037. You may also fax a request to 503-243-5105 or submit a request online using the preauthorization form. To obtain a preauthorization for Medicare Advantage members, complete and return the Medicare preauthorization form.

Urgent/emergent admissions

"Emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person, or a fetus in the case of a pregnant woman, in serious jeopardy.

Outpatient services

Preauthorization is required for certain outpatient services. The Referral and Authorization Guidelines Referral and Authorization Guidelines Referral and Authorization Guidelines is a list of services that require preauthorization and may require a review for medical necessity. Please review the guidelines or obtain the required preauthorization by calling Medical Intake at 503-243-4496, or toll-free at 800-258-2037. You may also fax a request to 503-243-5105 or submit online using the preauthorization form.

Authorization requirements for outpatient behavioral health services vary by plan. For further information, please call Moda Health Behavioral Health at 503-624-9382 or 800-799-9391.

Moda Health Commercial Plans

Moda Health Provider Network

Find a physician, pharmacy or clinic

Opt in for medical

Tell us you're interested and we'll be in touch with details.

Get Started  Get Started

Questions?

If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service

Questions?

If you can't find an answer, please feel free to contact our Customer Service

Employer web tools

Benefit Tracker

Check benefits and eligibility

Log in

Account help

Request an account

Provider Reports

For Synergy, Summit, and EOCCO provider contacts

Log in

Join our email list


Benefit Tracker

Check benefits, eligibility, incentive and utilization

Log In

Account help

Create an account

Producer web tools


Hello.

We have exciting news to share. ODS is changing its name to Moda Health.

Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.

Together, we can be more, be better.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

Hello.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

Changing your location to Oregon

You can return to your previous location in the site header.