Member FAQs
- How do I know what plan I have?
- Can I view my plan summary and benefits online?
- Can I choose a primary care physician (PCP) or specialist online?
- What if my doctor or dentist no longer participates with Moda Health and I want to continue seeing him or her?
- Do I have to call customer service to update my account or can I do it through the website?
- How do I add or drop a member of my family on my plan?
- How do I add or drop a member of my family on my plan?
- I have other group coverage - will Moda Health coordinate benefits?
- My co-worker has a question, but he doesn't speak English very well. Can you help?
- What if I'm not sure if I have medical or dental eligibility?
- How do I sign up my new baby for a plan?
- How do I order an ID card?
- How do I read my Explanation of Benefits (EOB)?
- How do I file a claim?
- How does Moda Health determine the allowable amount for medical services and procedures?
- What if the answers to my questions are not here?
- I can't find my provider, is there a list of providers that have ended their contract with Moda Health?
- What steps do I take if I need Durable Medical Equipment (DME)?
- What is DME?
How do I know what plan I have?
The type of plan you have and what network you can use is printed at the top of your ID card as well as on the cover of your Member Handbook. You can access your Member Handbook and other account information by logging in to your Member Dashboard account.
Can I view my plan summary and benefits online?
Yes, you can view your summary and benefit information online by accessing your member website, Member Dashboard. You also can download your Member Handbook from Member Dashboard to view this information.
Can I choose a primary care physician (PCP) or specialist online?
Yes, you can select a primary care physician (PCP) online. To find a physician in your area, go to our find care directory. If you're signing up for a new PCP, be sure to contact the physician's office to verify that he or she is accepting new patients. When you have selected a PCP who is accepting patients, contact Moda Health Customer Service or register online. A new ID card will be sent to you within five to 10 working days. You can change PCPs up to two times per year. Remember, your new PCP is effective at the beginning of the next month.
You also can find specialists online through the find care directory. Depending on your plan type, you may need a referral to see them. If that is the case, your PCP will refer you for specialty care, including both physician and hospital services.
What do I do if my doctor or dentist no longer participates with Moda Health and I want to continue seeing him or her?
Medical: Your plan may have a continuity of care provision that will enable you to continue care with the physician for a limited period of time. If continuity of care applies to your plan, it will be described in your Member Handbook. You also can contact Moda Health Medical Customer Service for information.
Dental: Under most Moda Health plans, you can see any licensed dentist whether his or her status is participating or not. Please contact Moda Health Dental Customer Service for assistance with a provider search and for additional questions.
Do I have to call customer service to update my account or can I do it through the website?
Please call our Customer Service team to update your account but note that some employers share that data with us, so we recommend contacting your HR group too if you are on plan from your employer.
How do I add or drop a member of my family on my plan?
To add or drop a dependent on your plan, you will need to contact your employer's HR department. The only time Moda Health will drop a dependent automatically is when he or she exceeds the age limit.
I have other group coverage - will Moda Health coordinate benefits?
Generally, yes. It is important that you notify us of your other group coverage on your medical and dental enrollment forms so that we know to coordinate benefits. Please contact Moda Health Customer Service for more information.
Generally, yes. It is important that you notify us of your other coverage on your medical enrollment form so that we know to coordinate benefits. Please contact Moda Health Customer Service for more information.
My co-worker has a question, but he doesn't speak English very well. Can you help?
Yes, we can help. for all medical, pharmacy and dental plans, and for Oregon Health Plan dental and medical customers. Simply have your co-worker contact Moda Health Customer Service, and one of our representatives will coordinate the services of an interpreter over the phone.
Yes, we can help with all medical and pharmacy plans. Simply have your co-worker contact Moda Health Customer Service, and one of our representatives will coordinate the services of an interpreter over the phone.
What if I'm not sure if I have medical or dental eligibility?
To verify your eligibility, you or your provider should contact Moda Health Customer Service. Your provider also can check your eligibility by visiting our website and logging on to Benefit Tracker. Providers must be participating in our free Benefit Tracker program to check your eligibility online.
How do I sign up my new baby for a plan?
Congratulations on your new arrival! You have the option of adding your baby to your plan. You must add your baby within 31 days of his or her birth. You will need to contact your employer as soon as possible so that the baby can be enrolled on the group plan. If you have purchased an individual plan, please contact Moda Health Customer Service.
Congratulations on your new arrival! ! You have the option of adding your baby to your plan. You must add your baby within 31 days of his or her birth. If you have purchased an individual plan, please contact Moda Health Customer Service.
How do I order an ID card?
An ID card will be sent to you upon enrollment in a Moda Health plan. To order a new medical or dental ID card, please log on to Member Dashboard and select "Request ID cards" from the member shortcuts panel. You also can contact Moda Health Customer Service. If you have purchased an individual dental plan, please contact Moda Health Customer Service.
How do I read my Explanation of Benefits (EOB)?
We have provided an Explanation of Benefits (EOB) sample for you to read.
How do I file a claim?
Medical claims
You can access claims forms by logging in to your Member Dashboard
Please include the following information:
Once your claim is ready, please send to:
Medical claims
Moda Health
P.O. Box 40384
Portland, OR 97240-0384
Dental claims
Moda Health
601 S.W. 2nd Ave.
Portland, OR 97204
Pharmacy claims
Moda Health
P.O. Box 40168
Portland, OR 97240
Major medical groups, please submit your pharmacy claims to:
Moda Health
P.O. Box 40384
Portland, OR 97240-0384
- Patient's name, identification number and group ID number
- Date of treatment
- Diagnosis (medical only)
- An itemized description of services and charges
If the treatment is for an accidental injury, include a statement with the date, time, place and circumstances of the accident when you send us the physician or professional provider's bill.
How does Moda Health determine the allowable amount for medical services and procedures?
Moda Health uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures.
MPA is the maximum amount that Moda Health will reimburse physicians and providers. For an in-network physician or provider, the maximum amount is the amount the provider has agreed to accept for a particular service.
For service by an out-of-network physician or provider, Moda Health will process charges for services as follows: the maximum allowable amount is the lesser of the amount payable under any supplemental provider fee arrangements we may have in place and a plan's standard allowable amount. Depending on the plan you have, the standard allowable amount may be based on one of the following:
- a percent at or above what Medicare would allow for the service;
- a percentile of fees commonly charged for a given procedure in a given area, based on a national database;
- acquisition cost;
- a percent of billed charges
Check your member handbook to determine how MPA is calculated for your particular plan.
For services provided by an out-of-network physician or provider, the amount above the MPA is the patient's responsibility. Depending on the plan, provisions deductibles and coinsurance may apply.
Please call Moda Health Medical Customer Service if you have any additional questions or concerns. We will be happy to help answer your questions.
What if the answers to my questions are not here?
If you can't find answers to your questions here, we offer other options on our website where you might find the information you're looking for. For instance, your Member Handbook outlines your plan details. You can access your Member Handbook by logging on to Member Dashboard. You also can contact your benefits department for more information or call or email the Moda Health Customer Service team.
I can't find my provider, is there a list of providers that have ended their contract with Moda Health?
Yes, please visit our list of Moda Health termed providers.
What steps do I take if I need Durable Medical Equipment (DME)?
If you are a member with new or recurring DME needs, just follow these easy steps to search for an in-network DME provider:
- Simply call the medical customer service number on the back of your member ID card to find out which providers offer the Durable Medical Equipment you need.
- Or you can log in to your Member Dashboard account.
- Go to Find Care and choose the “Durable Medical Equipment” option under the Specialty drop-down menu.
- Enter your ZIP code and Search.
- This will bring up the list of DME providers. Preferred providers will have a DME badge icon next to the networks where they are available.
What is DME?
DME is equipment and related supplies that primarily help members manage a medical condition. DME includes things like breast pumps, CPAP, wheelchairs, walkers, oxygen, and diabetic or ostomy supplies. They are durable because they last a long time. They don't get used up like medical supplies.
Plans may cover the rental charge or DME (but not exceed the purchase price). Members can work with their provider to order their prescribed DME.
Questions?
Please see your Member Handbook to determine what is covered by your benefits.
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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We have exciting news to share. ODS is changing its name to Moda Health.
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