Appeals and grievances

Filing a complaint

If you have concerns or problems with any part of your benefits, care, service or prescription drugs; you can file a complaint. Appeals and grievances are the two types of complaints you can file.

Filing an appeal

If you do not agree with a decision we have made, you can make an appeal (a request to change the decision). You can do this for decisions about services and payment. You can also request that we cover an item or service that is not in your plan.

If you need to ask for a review of a medical care coverage decision made by our plan, you or your provider may do one of the following:

  • Submit a written request and fax to 503-412-4003
  • Submit a written request and mail to:

Moda Health
Attn: Medicare Appeal and Grievance Unit
P.O. Box 40384
Portland, OR 97240-0384

For pharmacy appeals:

Learn more about making a pharmacy appeal in your Evidence of Coverage.

If your health requires a quick response, you must ask for a “fast appeal.” For an expedited appeal, you or your provider may do one of the following:

  • Call 866-796-3221.
  • Submit a written request and fax to 503-412-4003, Attn: Medicare Expedited Appeal and Grievance Unit
  • Submit a written request and mail to:

Moda Health
Attn: Medicare Appeal and Grievance Unit
P.O. Box 40384
Portland, OR 97240-0384

Please make sure to write “expedited appeal” on your request.

Learn more about making an appeal in your Evidence of Coverage.

Filing a grievance

If you are not satisfied with us or one of our providers, you can file a grievance. A grievance is not for coverage or payment. Learn more about filing a grievance in your Evidence of Coverage.

Need help filing an appeal or grievance? Please call Moda Health Member Services at 503-265-4762 or toll-free at 844-721-4938. TTY users, dial 711. Member Services is available from 7 a.m. to 8 p.m., Monday through Friday. Weekend calls are forwarded to voicemail and returned the next day.  You can also find out how many appeals, grievances and exceptions we have received. Just ask us.

If you choose to mail your grievance, send it to:

Moda Health Plan, Inc.
Attn: Moda Health Medicare Appeals
P.O. Box 40384
Portland, OR 97240-0384

Appointing a representative

You can assign someone you trust to request authorization, or file a claim, grievance or appeal. To do this, please complete our Appointment of Representative form. You will need to have the person you appoint sign the form. You can submit this form with your appeal or grievance request.

Filing a complaint with Medicare

We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online complaint form.

Last updated Dec. 19, 2018
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