Moda Health. Healthcare from your head to your toes. Delta Dental | Moda Health

Medical necessity criteria

Jump to:

Moda Health Commercial Plans Criteria

Moda Health Medicare Advantage Plans

Moda Health may develop or adopt medical necessity criteria for certain complex, high cost or highly utilized services on the prior authorization list that do not have an existing National Coverage Determination, Local Coverage Determination, Local Coverage Article, or applicable clinical care guidelines associated with them. These services include, but are not limited to, new technologies (Medical, Behavioral Health, Pharmaceuticals, Devices), new medications and frequently requested services by healthcare providers that require a review for medical necessity.

Medical Necessity Criteria is developed using published scientific evidence and information from relevant governmental regulatory bodies. The criteria is reviewed by the Medical Director, Licensed Psychiatrist, and/or an external specialist review for content and appropriateness.

We have created a complete list of medical necessity criteria for Medicare Advantage below:

Injectable Medication Criteria

MagellanRx - Moda Health Plan Delegates administrative functions to MagellanRx. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, ??50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Some injectable medications are reviewed by Moda Health. Please see the bottom of the Injectable Medication Prior Authorization List to find out which medications should be submitted to Moda Health.

Moda Health Provider Network

Find a physician, pharmacy or clinic

Opt in for medical

Tell us you're interested and we'll be in touch with details.

Get Started  Get Started

Member Dashboard

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

Employer web tools

Benefit Tracker

Check benefits and eligibility

Log in

Account help

Request an account

Provider Reports

For value-based provider programs, including Synergy, Summit, Beacon, Affinity, CPC+, and EOCCO

Log in

Join our email list

Sign up

Benefit Tracker

Check benefits, eligibility, incentive and utilization

Log In

Account help

Create an account

Rate finder is now in the Producer Dashboard

Log in with your current username and password to create quotes for groups up to 50.

Producer Dashboard
Log in


Hello.

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.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

Hello.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

Changing your location to Oregon

You can return to your previous location in the site header.