Out-of-network liability and balance-billing

Moda Health uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures. For air ambulance, emergency care and some non-emergency care where patients do not have the ability to choose an in-network provider, MPA is the 80th percentile of fees based on a national database, the median in-network rate, and the Medicare allowable amount, whichever is greatest.

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 beyond the MPA may be the member's responsibility.

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

When a Moda Health member visits an in-network facility and is not able to choose the provider, the provider cannot balance bill the member for services provided out-of-network except when permitted by law.

If a member 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, and the member is only responsible for the plan cost sharing such as deductible, copay and coinsurance. Providers cannot balance bill the member for emergency care provided out-of-network except when permitted by law.

If a member has a medical emergency and needs air ambulance services, the service will be paid at the in-network benefit level and the out-of-network provider cannot balance bill the member except when permitted by law.

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. Instead, members should 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, they may submit an itemized receipt with details about the date of service, the service provided and the amount for the service.

Claims need to be filed to one of the following addresses within 12 months of the date of service:

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

Pharmacy Claims
Navitus Health Solutions, LLC
P.O. Box 999
Appleton, WI 54912-0999

For additional questions or assistance, members can call our customer service team at 888-873-1395 for medical claims or 844-235-8016 for pharmacy claims.

Alaska members can call 888-873-1395 for medical claims or 844-235-8016 for pharmacy claims.

Grace periods and claims pending

A grace period to pay premiums (the monthly amount members pay to be covered by a health plan) 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 one month's premium are eligible for a three-month grace period. Claims received during the first month 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. To learn more, members should check their handbooks.

Retroactive denials

A retroactive denial is the reversal of a claim that Moda Health has already paid. If Moda Health retroactively denies a claim that has already been paid, the member will be responsible for payment. Some reasons why a member might have a retroactive denial include having a claim that was paid during a grace period or having a claim paid for a service for which the member was not eligible. Members can avoid retroactive denials by paying their premiums on time and in full and making sure they talk to their provider about whether the service performed is a covered benefit.

If premiums are not paid for the first month of coverage or within the grace period, member coverage will be retroactively terminated, effective on the last month that the premium was paid. Claims will be denied for any months that members do not have active coverage.

Member reimbursement for premium overpayments

Moda Health reconciles member accounts on a monthly basis. Any overpayments are refunded to the member or credited to the next month's bill. Members receive a statement that reflects the adjustments to their account. Members who want to request a reimbursement or who have questions about the process may call Customer Service at 888-873-1395.

Medical necessity and prior authorization timeframes and member responsibilities

Prior authorization is used to determine if a service is covered or medically necessary before the service is provided. A prior authorization is not required for emergency services. To learn more, members may call customer service or view our list of services that require prior authorization.

Members can check their handbooks for specifics about prior authorization requirements. Based on the service and the member's plan, except for emergency services, failure to get a required prior authorization can lead to a penalty of 50%, up to a maximum of $2,500 in Alaska plans.

In nonemergency cases, prior authorization decisions are made within five (5) business days of receiving a request. In the case of an emergency, decisions for care following emergency services will be made as soon as possible, no later than 24 hours after receiving prior authorization.

Medications exception timeframes and member responsibilities

Requests for formulary exceptions, including requests for an expedited review due to exigent circumstances, can be made through CoverMyMeds or by contacting Customer Service at 888-361-1610. Formulary exceptions must be based on medical necessity. The prescribing professional provider's contact information must be submitted, as well as information to support the medical necessity, including all of the following:

1. Formulary medications were tried with an adequate dose and duration of therapy
2. Formulary medications were not tolerated or were not effective
3. Formulary or preferred medications would reasonably be expected to cause harm or not produce equivalent results as the requested medication
4. The requested medication therapy is evidence-based and generally accepted medical practice

Moda Health will contact the prescribing professional provider to find out how the medication is being used in the member's treatment plan. Standard exception requests are determined within 48 business hours. Urgent requests are determined within 24 hours.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third party reviewer know as an independent review organization (IRO). We must follow the IRO's decision. An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, emailing, or faxing the request to:

Alaska Division of Insurance
550 West 7th Avenue Suite 1560
Anchorage, AK 99501-3567

Fax: 907-269-7910
Email: insurance@alaska.gov

Explanation of Benefits (EOB)

Moda Health will report its action on a claim by providing the member an Explanation of Benefits (EOB). Members are encouraged to access their EOBs online by signing up through the Member Dashboard. Moda Health may pay claims, deny claims, or accumulate them toward meeting the deductible, (the amount of money members pay in a calendar year for care before the health plan starts paying), if any. If all or part of a claim is denied, the reason will be stated on the EOB. For help reading or understanding an EOB, members can call Customer Service at 888-873-1395 or see the "How to read an EOB" document for more information. If a member does not receive an EOB or email letting them know that an EOB will be available within a few weeks of the date of service, this may mean 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 the member an EOB explaining the denial within 30 days of receiving the claim.

If more 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 the reason(s) within 30 days after Moda Health receives the claim. Moda Health will then complete its processing and send the member an EOB no more than 45 days after receiving the claim.

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

Once the 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 the original date the claim was received. Submission of information needed to process a claim is subject to the plan's 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 works with other insurers to help the member get the most out of those plans. By coordinating benefits, Moda Health may be able to reduce the member's out-of-pocket expenses for covered services.

During initial enrollment and each year, Moda Health asks each member about any other health insurance coverage they may have to see if any changes 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 can let us know by completing this Coordination of Benefits form and returning it to Moda Health. Or, they can call our customer service team at 888-873-1395.