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Moda Health HMO organization determination, coverage determination, appeal and grievance procedures

Organization determination

An organization determination is a coverage decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need

Prior authorization is approval in advance to get services. Some in-network medical services are covered only if your provider gets prior authorization from our plan. You do not need prior authorization to obtain out-of-network services or emergency services. Covered services that need prior authorization are listed in the Benefits Chart of your Evidence of Coverage.

To request an organization determination or prior authorization, you or your provider can call Moda Health Healthcare Services at 1-800-592-8283 or fax a prior authorization request form to 1-855-637-2666. Moda Health Healthcare Services hours of operation are from 7 a.m. to 4:30 p.m. Pacific time, Monday through Friday. (TTY users call 711.)

Coverage determination

Coverage determination is a decision we make about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write us to ask for a formal decision about the coverage if you disagree.

Exception

An exception is a type of coverage determination that, if approved, allows you to obtain a Part D-eligible drug that is not on our formulary (a formulary exception). You may also request an exception if we require you to try another drug before receiving the drug that you are requesting (step therapy) or we limit the quantity or dosage of the drug that you are requesting.

You can mail coverage determinations and exception requests to:

Moda Health Plan, Inc.
Attn: Moda Health Pharmacy Customer Service
P.O. Box 40327
Portland, OR 97240-0327

You may also fax to: 1-800-207-8235

If you have questions or need help with your appeal, coverage determination, exception request, redetermination or grievance, please call customer service.

Complaints

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, service, or drugs, as a Moda Health HMO 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 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 HMO plan includes an explanation of appeals, including the process involved in making an appeal.

Prescription drug appeal forms:

  • Prescription drug redetermination request
    Use the link above to request an appeal, or redetermination, of a denied exception or coverage determination. This is a secure form and all member information is protected through this submission process. If you would prefer to fill out this form and send it in via mail or fax, you can download the prescription drug redetermination request form and follow the instructions at the top of the form. Note: You must receive a denied coverage determination before requesting a redetermination.

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 HMO plan, you will find more information about how to make a complaint.

If you have questions or need help with your organization determination, appeal, coverage determination, exception request, redetermination or grievance, please call member services. You can mail your appeal, redetermination 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.

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.

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

Medicare.gov complaint website

The Centers for Medicare and Medicaid Services (CMS) developed an electronic complaint form that is available on Medicare.gov. The following link Medicare Complaint Form will take you directly to the complaint form.

Last updated June 1, 2018
Y0115_WEB_2018A Approved

We're sorry, we don't currently offer Medicare plans in . View our plans in or use the dropdown at the top of the page to view Medicare plans in Oregon.

Moda Health HMO (HMO-POS) 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 HMO (HMO-POS) 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 HMO (HMO-POS) 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 HMO (HMO-POS) 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 HMO grievances and appeals, please call member services.

Last updated October 1, 2016
Y0115_WEB_2017A Approved

We're sorry, we don't currently offer Medicare plans in . View our plans in or use the dropdown at the top of the page to view Medicare plans in Oregon.

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