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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

Durable Medical Equipment (DME)

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 MagellanRx.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

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