Claims and appeals
For Claims and Appeals, please see procedures below based on line of business.
Medical claims
You may dramatically reduce the processing time for your claim if you:
- Submit claims electronically - Moda Health processes electronic claims first each day
- Verify the patient's relationship to the subscriber and plan information is correct before submitting claims
- Include all pertinent information - date of birth, subscriber ID, valid CPT and ICD-10 codes
- If the patient is covered by more than one Moda Health program, submit one claim form indicating the name of the subscriber, subscriber ID, employer (if applicable) and Moda Health group number for both plans - if covered by another carrier, indicate the above information plus the name, address and policy number of the other carrier.
- If a patient has primary insurance through another carrier other than Moda Health, the EOB from that insurance company will need to accompany the claim for consideration of payment.
- Moda Health makes payment weekly.
- Please contact us before submitting duplicate claims:
- Rebilling without contacting us slows our turnaround time and delays payment.
- Check Benefit Tracker to see the status of a claim. If you haven't registered for this free online service, click here for more information.
- If you receive a PDR indicating that your claim has already been processed before you receive a check, this indicates your re-bill was unnecessary. The claim was processed and is pending for the next scheduled payment date.
- DO NOT USE HIGHLIGHTER ON PAPER CLAIMS.
Electronic claims and other transactions
Moda Health is interested in receiving claims electronically.
The advantages for your office include:
- The claim reaches Moda Health faster, usually anywhere from just seconds to 24 hours, depending on the connection.
- Your office and Moda Health have lower administrative costs.
- Because electronic claims require consistent, accurate information, the incidence of returning claims to your office is reduced.
Below is a list of Medical and Hospital Electronic Claims Providers for Moda Health:
Availity
12400 Coit Rd. #700
Dallas, TX 75251
800-282-4548
Payor ID = 13350
ChangeHealthcare (formerly Emdeon) (both medical and hospital)
(RelayHealth merged with ChangeHealthcare)
424 Church Street Suite 1400
Nashville, TN 37219
Customer Support 866-371-9066
Payor ID = 13350
MCPS Inc
1740 S. Glenstone #B
Springfield, MO 65804
417-890-6164
MD On-Line Inc.
6 Century Dr
Parsippany, NJ,07054
888-499-5465
Office Ally
PO Box 872020
Vancouver, WA 98687
360-975-7000
Systems that submit directly to Moda Health:
LINCARE Inc.
19387 US 19 N
Clearwater, FL 33764
727-431-8231
DIRECT CONNECTION TO MODA HEALTH
Moda Health also supports direct connections between offices and Moda Health if the doctor or health system prefers this method. The transaction standard is the 837 Professional Claim or 837 Institutional Claim required by HIPAA Administrative Simplification.
Moda Health EDI transactions contacts
Email edigroup@modahealth.com
Reasons for denied, paid at a lower benefit or returned claims
- Patient is not eligible. A member's card is NOT a guarantee of eligibility.
- Coverage has terminated.
- Claim received with incomplete information. Please remember to include the following:
- Subscriber ID
- Group number
- Date of birth
- CPT code
- ICD-10 code
- Full name and address of provider with the tax ID number
- No authorization on file for procedure.
- No PCP selected by member.
- Member was seen by specialist for routine services. These services must be done by the member's PCP.
- Member was seen by PCP's on-call physician and claim did not indicate this. Please indicate by stating on top of claim "ON-CALL." This will alert our processors that the physician used was on-call for the member's PCP.
- Member has other primary coverage, and EOB was not received with claim.
- Procedure or service is a noncovered service. Please contact Moda Health Customer Service to verify whether the procedure is a covered service or if you have any questions.
Appeals
Non-Contracted Providers:
If you are a non-contracted provider, you have 60 calendar days from the remittance notification date to file a request for reconsideration of the plan’s denial of payment. Non-contracted providers must sign a Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal. Download form: Medicare Waiver of Liability.
Non-contracted providers should include documentation such as a copy of the original claim, remittance notification showing denial, and any clinical records and other documentation that supports the provider’s argument for reimbursement.
Request for reconsideration should be sent to Moda Health, ATTN: Medicare Appeals Unit at P.O. Box 40384, Portland, OR 97204 or faxed to 503-412-4003.
Full instructions can be found here: Download the full instructions: Non-Contracted Provider Appeals & Provider Payment Disputes.
Contracted Providers Disputes
Contracted Providers:
Please refer to your Contract with Moda Health to determine reconsiderations rights.
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
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