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Moda Health PPORX (PPO) medical appeal and grievance procedure

Our goal is to provide you with coverage and services that always exceed your expectations. However, if you have concerns or problems with any part of your benefits, care or service, as a Moda Health PPORX member, you have the right to file a complaint.

There are two types of complaints: appeals and grievances.

Appeal

You can make an appeal if you disagree with a decision to deny a request for healthcare services or payment for services you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for an item or service you think you should be able to receive.

Chapter 9 of the Evidence of Coverage booklet for the Moda Health PPORX plan includes an explanation of appeals, including the process involved in making an appeal.

Grievance

A grievance is a type of complaint you make about Moda Health or one of our network providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. In Chapter 9 of the Evidence of Coverage booklet for the Moda Health PPORX plan, you will find more information about how to make a complaint.

More information

Appointment of Representative form: Use this form to name a relative, friend, advocate, doctor or anyone else as your appointed representative. This person may request an organization determination or file a grievance or appeal on your behalf. If you want someone to act for you, then you and that person must sign the Appointment of Representative form, giving that person legal permission to act as your appointed representative.

If you have questions or need help with your appeal or grievance, please call member services. You can mail your appeal or grievance to:

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

You may also fax it to: 503-412-4003.

For a report on the number of Moda Health PPORX grievances and appeals, please call member services.

Last updated October 1, 2016
Y0115_WEB_2017A Approved

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