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Transparency in coverage

Out-of-network liability and balance-billing

Moda Health uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures.

MPA is the maximum amount that Moda Health will reimburse out-of-network physicians and providers. For services provided by an out-of-network physician or provider, the amount above the MPA may be the memberís responsibility.

If a member is out of the service area and has a medical emergency, the member should go to the nearest emergency room or urgent care center. Emergency care benefits will be paid at the in-network benefit level, subject to the maximum plan allowable for emergency services.

For an in-network physician or provider, the maximum amount is the amount the provider has agreed to accept for a particular service.

Member claims submission

All in-network providers and most out-of-network providers will bill Moda Health. Out-of-network pharmacies will not bill Moda Health. Members should instead submit a claim for out-of-network pharmacy services. If members need to send a claim they can download and mail a claim form or submit an itemized receipt with information about the date of service, the service provided and the amount of service.

Claims need to be filed within 12 months of the date of service.

Medical Claims
Moda Health
P.O. Box 40384
Portland, OR 97240-0384

Pharmacy Claims
Moda Health
P.O. Box 40168
Portland, OR 97240-0168

For additional help, members can call our team of customer service experts toll-free at 888-217-2363 for medical claims or 888-361-1610 for pharmacy claims.

Grace periods and claims pending

A grace period to pay premiums is an extension of the due date. If premiums are paid during the grace period there is no interruption of coverage. Individual members who receive the advance premium tax credit (APTC) and have paid their first month of premium are eligible for a three-month grace period. Claims received during the first 30 days will be processed on schedule. Claims received during the remaining grace period will be considered pending (not paid or denied) until Moda Health receives the premium.

Grace periods and claims pending procedures for members not receiving APTC are different. Members should consult their handbooks for more information.

Retroactive denials

If premiums are not paid for the first month of coverage or within the applicable grace period, members will be retroactively terminated, effective on the last month that the premium was paid. Claims will be denied for any months in which members do not have active coverage. Members receive a bill and a delinquency notice in an effort to keep premiums paid on time, maintain coverage and avoid a lapse of benefits.

Member reimbursement for premium overpayments

Moda Health reconciles accounts on a monthly basis. Any overpayment discrepancies are refunded to the member or credited to the next month’s bill. Members receive a statement reflecting the method of adjustment. Members who want to request a reimbursement or who have questions about the process, are encouraged to contact Customer Service at 888-217-2363.

Medical necessity and prior authorization timeframes and member responsibilities

Prior authorization is used to determine whether a service is covered (including whether it is medically necessary) before the service is provided. Prior authorization is not required for emergency services. Members may contact Customer Service or proceed to our list of services that require prior authorization.

Members may consult their handbooks for specifics about prior authorization requirements. Depending on the service and the memberís plan, except for emergency services, failure to obtain required prior authorizations can result in a complete denial of benefits in Oregon plans or a penalty of 50 percent, up to a maximum of $2,500 in Alaska plans.

The timeframe for processing prior authorization requests varies by state as follows:

Alaska plans

In nonemergency cases, prior authorization decisions are made within five business days of receipt of the request. For emergency situations, decisions for care following emergency services will be made as soon as possible no later than 24 hours after receiving the request for prior authorization.

Oregon plans

Moda Health will respond to prior authorization requests within two business days. The response time will be expedited if the member has an urgent medical condition.

Medications exception timeframes and member responsibilities

Moda Health individual and small group plans provide prescription medication coverage under an open formulary. Members will never need to request an exception for a nonformulary medication while covered under a Moda Health individual or small group plan.

While the nonformulary exception process is not needed, some limitations apply. For example, some medications require that members meet certain medical criteria. Member’s cost-share for a medication depends on the benefit tier of the medication and the terms of their plan. For information about those processes, members may consult their handbooks or call Customer Service at 888-361-1610.

Explanation of Benefits (EOBs)

Moda Health will report its action on a claim by providing the member a document called an Explanation of Benefits (EOB). Members are encouraged to access their EOBs electronically by signing up through myModa. Moda Health may pay claims, deny them, or accumulate them toward satisfying the deductible, if any. If all or part of a claim is denied, the reason will be stated in the EOB. For help reading and understanding an EOB, members are encouraged to call Customer Service at 888-217-2363 or see the “How to read an EOB” document for more information. If a member does not receive an EOB or an email letting them know that an EOB is available within a few weeks of the date of service, this may indicate that Moda Health has not received the claim. To be eligible for reimbursement, claims must be received within the claim submission period.

Timeframes for processing claims

If a claim is denied, Moda Health will send an EOB explaining the denial within 30 days of receiving the claim.

If additional time is needed to process the claim for reasons beyond Moda Health’s control, a notice of delay will be sent to the member explaining those reasons within 30 days after Moda Health receives the claim. Moda Health will then complete its processing and send an EOB to the member no more than 45 days after receiving the claim.

If additional information is needed to complete processing of the claim, the notice of delay will describe the information needed. The party responsible for providing the additional information will have 45 days to submit it.

Once the additional information is received, processing of the claim will be completed within 15 days in Oregon and in Alaska within 15 days after receiving the information or 30 days of original receipt date of the claim. Submission of information necessary to process a claim is subject to the planís claim submission period.

Coordination of Benefits (COB)

Coordination of Benefits (COB) occurs when a member has healthcare coverage under more than one plan.

If a member is covered by more than one medical, vision, pharmacy or dental health plan, Moda Health coordinates benefits with other insurers to help the member receive the full benefit of those plans. By coordinating benefits, Moda Health may be able to reduce the member’s out-of-pocket expenses for covered services.

Upon initial enrollment and annually, Moda Health requests information from each member regarding any other health insurance coverage they may have to verify any changes that may have happened during the year. In order to prevent a claim from being delayed or denied, members should let Moda Health know if they or anyone in their family have any other current medical, vision, pharmacy or dental coverage that has existed in the last 12 months. This includes Medicare and Medicaid. Members let us know by completing this Coordination of Benefits form and returning it to Moda Health. Members can also call Customer Service at 888-217-2363.

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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.

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