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MEMBER DASHBOARD
Log in to the Member Dashboard. Use the Member Dashboard to get real-time views into your claims and benefits for Moda Health and/or Delta Dental members. DENTAL BENEFIT TRACKER HELP 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: Select a state. 101 LOW-COST IDEAS FOR WORKSITE WELLNESS 101 Low-cost ideas for worksite wellness The following ideas for worksite wellness can be implemented with limited resources. Many of these ideas have been found to help employees of all physical abilities maintain their health. 2021 MEDICAL PLAN BENEFIT SUMMARY This document is provided for informational purposes only, and is intended as a quick reference of Moda Health plan benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. EVKEEZA™ (EVINACUMAB-DGNB) Page 2 | EVKEEZA™ (evinacumab) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy without approval. ©2021, Magellan Rx Management EMERGENCY DEPARTMENT VISIT LEVELING 1. When a physician bills a Level 4 (99284) or Level 5 (99285) emergency room E/M service, with a diagnosis indicating a lower level ofacuity, complexity, or severity, theservice will automatically CLINIC SERVICES IN THE HOSPITAL OUTPATIENT SETTING For clinic visits and services performed in the hospital outpatient setting, Moda Health does not allow split-billing of Providerbased clinic services as allowed by CMS for its Original Medicare business. DRG PAYMENT WITH PATIENT TRANSFERS 1. Transferring Hospital. a. It is important to note that a hospital may discharge a patient, but later become a Transferring Hospital if and when the patient is readmitted to the same or another inpatient TRELSTAR® (TRIPTORELIN) Page 2 | TRELSTAR® (triptorelin) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy withoutapproval.
MODIFIERS PO & PN FOR G0463 CLINIC VISIT SERVICES Page 4 of 5 . rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act (departments that bill the modifier“PO” on
MEMBER DASHBOARD
Log in to the Member Dashboard. Use the Member Dashboard to get real-time views into your claims and benefits for Moda Health and/or Delta Dental members. DENTAL BENEFIT TRACKER HELP 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: Select a state. 101 LOW-COST IDEAS FOR WORKSITE WELLNESS 101 Low-cost ideas for worksite wellness The following ideas for worksite wellness can be implemented with limited resources. Many of these ideas have been found to help employees of all physical abilities maintain their health. 2021 MEDICAL PLAN BENEFIT SUMMARY This document is provided for informational purposes only, and is intended as a quick reference of Moda Health plan benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. EVKEEZA™ (EVINACUMAB-DGNB) Page 2 | EVKEEZA™ (evinacumab) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy without approval. ©2021, Magellan Rx Management EMERGENCY DEPARTMENT VISIT LEVELING 1. When a physician bills a Level 4 (99284) or Level 5 (99285) emergency room E/M service, with a diagnosis indicating a lower level ofacuity, complexity, or severity, theservice will automatically CLINIC SERVICES IN THE HOSPITAL OUTPATIENT SETTING For clinic visits and services performed in the hospital outpatient setting, Moda Health does not allow split-billing of Providerbased clinic services as allowed by CMS for its Original Medicare business. DRG PAYMENT WITH PATIENT TRANSFERS 1. Transferring Hospital. a. It is important to note that a hospital may discharge a patient, but later become a Transferring Hospital if and when the patient is readmitted to the same or another inpatient TRELSTAR® (TRIPTORELIN) Page 2 | TRELSTAR® (triptorelin) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy withoutapproval.
MODIFIERS PO & PN FOR G0463 CLINIC VISIT SERVICES Page 4 of 5 . rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act (departments that bill the modifier“PO” on
MODA HEALTH
Medical provider search. Search for your providers — doctors, clinics or hospitals — to see if they are in the for 2021. You can save and add primary care providers (PCPs) to your enrollmentapplication.
PEBB: HOME - MODA HEALTH Through the Synergy Network, members can access high-quality care, close to home. After enrolling in their Synergy plan, members choose a Medical Home from a diverse and wide selection of participating providers, throughout the network. Hospitals and health systems affiliated with the Summit network include: Adventist Health. PROCEDURES AND SERVICES Description CPT/HCPC Codes Instructions Alpha 1 Proteinase Inhibitors - (Glassia ®, Aralast NP®, Prolastin®, Prolastin - C®, Zemaira®) J0256, J0257 As of 1/1/17 -Request for authorization is provided by Magellan RX for all fully insured groups and individuals. HYDROGEN BREATH TESTING Moda Health Medical Necessity Criteria Page 1/3 Hydrogen Breath Testing Date of Origin: 03/27/2019 Last Review Date: 03/25/2020 Effective Date: 04/01/2020 PEPAXTO® (MELPHALAN FLUFENAMIDE) Pepaxto® (melphalan flufenamide) (Intravenous) Last Review Date: 04/06/2021 Date of Origin: 04/06/2021 Dates Reviewed: 04/2021 I. Length of Authorization DRG PAYMENT WITH PATIENT TRANSFERS 1. Transferring Hospital. a. It is important to note that a hospital may discharge a patient, but later become a Transferring Hospital if and when the patient is readmitted to the same or another inpatient OFFICE OR OTHER OUTPATIENT EVALUATION AND MANAGEMENT (E/M A. Office or other outpatient evaluation and management (E/M) visits. Effective for dates of service 1/1/2021 and following. 1. The E/M coding changes for 2021 apply BENLYSTA® (BELIMUMAB) (INTRAVENOUS) 9. Gordon C, Amissah-Arthur MB, Gayed M, et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. FACILITY GUIDELINES, GENERAL OVERVIEW 1. Hospital observation is intended to allow a physician an opportunity to monitor and observe a patient and make a decision abouton-going care.
GYNECOLOGIC OR ANNUAL WOMEN’S EXAM VISIT & USE OF Q0091 3. Additional preventive services (e.g. a screening rectal exam, a health risk assessment, ordering covered preventive/screening labs and tests, -symptomatic or other assessment of a nonMEMBER DASHBOARD
Log in to the Member Dashboard. Use the Member Dashboard to get real-time views into your claims and benefits for Moda Health and/or Delta Dental members.EBILL - MODA HEALTH
Individuals & Families. If you are a member with an individual/family plan, log in to myModa and look for the eBill tab. Log in to MemberDashboard.
WASHINGTON STATE PRESCRIPTION SERVICES Register Now to: Get a price check on your prescriptions. Order refills for mail delivery. Find a network pharmacy near you. Get prescription claims history. View your benefits and claims information. Need Help? Washington State Prescription Services Web assistance. 877-277-7079. PROVIDER REFUND SUBMISSION FORM DATE Title: provider refund submission form (updated October 2020) Author: Moda Health / Delta Dental Created Date: 10/8/2020 1:45:46 PM DENTAL BENEFIT TRACKER HELP 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: Select a state. COMPLAINT AND APPEAL FORM Title: OR AK complaint / grievance / appeal form_Cobranded (updated October 2020) Author: Moda Health / Delta Dental Created Date: 10/5/2020 11:51:40 AMCARE PROGRAMS
< Return to overview. Credentialing forms Locum Tenens Form. A practitioner who is new to the Moda Health panel and provides coverage for an absent practitioner or due to practitioner shortage for a period of 90 consecutive calendar days or less is not required to complete the full credentialing process, but rather an expedited process that will approve credentialing for the Locum Tenens 2021 MEDICAL PLAN BENEFIT SUMMARY This document is provided for informational purposes only, and is intended as a quick reference of Moda Health plan benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. MODA HEALTH BEACON GOLD 1500 This document is provided for informational purposes only, and is intended as a quick reference of Moda Health plan benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. TRELSTAR® (TRIPTORELIN) Page 2 | TRELSTAR® (triptorelin) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy withoutapproval.
MEMBER DASHBOARD
Log in to the Member Dashboard. Use the Member Dashboard to get real-time views into your claims and benefits for Moda Health and/or Delta Dental members.EBILL - MODA HEALTH
Individuals & Families. If you are a member with an individual/family plan, log in to myModa and look for the eBill tab. Log in to MemberDashboard.
WASHINGTON STATE PRESCRIPTION SERVICES Register Now to: Get a price check on your prescriptions. Order refills for mail delivery. Find a network pharmacy near you. Get prescription claims history. View your benefits and claims information. Need Help? Washington State Prescription Services Web assistance. 877-277-7079. PROVIDER REFUND SUBMISSION FORM DATE Title: provider refund submission form (updated October 2020) Author: Moda Health / Delta Dental Created Date: 10/8/2020 1:45:46 PM DENTAL BENEFIT TRACKER HELP 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: Select a state. COMPLAINT AND APPEAL FORM Title: OR AK complaint / grievance / appeal form_Cobranded (updated October 2020) Author: Moda Health / Delta Dental Created Date: 10/5/2020 11:51:40 AMCARE PROGRAMS
< Return to overview. Credentialing forms Locum Tenens Form. A practitioner who is new to the Moda Health panel and provides coverage for an absent practitioner or due to practitioner shortage for a period of 90 consecutive calendar days or less is not required to complete the full credentialing process, but rather an expedited process that will approve credentialing for the Locum Tenens 2021 MEDICAL PLAN BENEFIT SUMMARY This document is provided for informational purposes only, and is intended as a quick reference of Moda Health plan benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. MODA HEALTH BEACON GOLD 1500 This document is provided for informational purposes only, and is intended as a quick reference of Moda Health plan benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. TRELSTAR® (TRIPTORELIN) Page 2 | TRELSTAR® (triptorelin) Prior Auth Criteria Proprietary Information. Restricted Access – Do not disseminate or copy withoutapproval.
MODA | MEDICARE 2021 Please call Moda Health Customer Service at 503-265-4762 or toll-free at 877-299-9062. TTY users, dial 711. Customer Service is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through March 31. (After March 31, your call will be handled by our automated phone system Saturdays, Sundays and holidays.) MODA COORDINATED CARE Coordinated care with Moda Health: PCP 360. With some Moda Health plans, you will also choose a PCP 360. A PCP 360 is a primary care provider who is part of a medical home — a facility that has been certified by the Oregon Patient-Centered Primary Care Program or othersimilar programs.
2021 COMPREHENSIVE FORMULARY (COMPLETE LIST OF COVERED DRUGS) ii 2021 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN questions, please contact Moda Health at 1-888-786-7509 or, for TTY users, 711, from 7 a.m. to 8MEMBERS: FORMS
Prescription compound drug claim form (use this form for services performed in 2020) Costco hearing aid reimbursement form. Dental claim form - members can access their dental claim form at their Member Dashboard. Medical/Vision Claim Form. Tobacco Cessation Claim Form. Medical/Vision Claim Form. Rx Drug Claim Form – Commercial MajorMedical.
PEBB: HOME - MODA HEALTH Through the Synergy Network, members can access high-quality care, close to home. After enrolling in their Synergy plan, members choose a Medical Home from a diverse and wide selection of participating providers, throughout the network. Hospitals and health systems affiliated with the Summit network include: Adventist Health.OREGON HEALTH PLAN
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. HYDROGEN BREATH TESTING Moda Health Medical Necessity Criteria Page 1/3 Hydrogen Breath Testing Date of Origin: 03/27/2019 Last Review Date: 03/25/2020 Effective Date: 04/01/2020 SUMMARY OF BENEFITS AND COVERAGE COMPLETED EXAMPLE For more information about your coverage, or to get a copy of the complete terms of coverage, contact Moda Health at www.modahealth.com or by calling 1-888-217-2363. EMERGENCY DEPARTMENT VISIT LEVELING 1. When a physician bills a Level 4 (99284) or Level 5 (99285) emergency room E/M service, with a diagnosis indicating a lower level ofacuity, complexity, or severity, theservice will automatically STAY ACTIVE AND FIT FOR LESS Moda, c. compies ith applicable edera civi right aws an oe ot iscriminate on the asi o race color ational origin, age, iability orex. AT i aa epao ay
MEMBER DASHBOARD
Log in to the Member Dashboard. Use the Member Dashboard to get real-time views into your claims and benefits for Moda Health and/or Delta Dental members.EBILL - MODA HEALTH
Individuals & Families. If you are a member with an individual/family plan, log in to myModa and look for the eBill tab. Log in to MemberDashboard.
LOGIN - MODA HEALTH
Login. You can find up-to-the-minute medical eligibility, benefits, claims and referral information online seven days a week. Username.Password.
MODA | MEDICARE 2021 Please call Moda Health Customer Service at 503-265-4762 or toll-free at 877-299-9062. TTY users, dial 711. Customer Service is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through March 31. (After March 31, your call will be handled by our automated phone system Saturdays, Sundays and holidays.)MODA HEALTH
PEBB members, learn about Moda Health medical and dental plans. Find a provider, or see if your provider is in our network. See our quarterly magazine, “The Well.” Find out about extra dental benefits, Virtual Visits and more. COMPLAINT AND APPEAL FORM Title: OR AK complaint / grievance / appeal form_Cobranded (updated October 2020) Author: Moda Health / Delta Dental Created Date: 10/5/2020 11:51:40 AM DENTAL BENEFIT TRACKER HELP 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: Select a state. PROCEDURES AND SERVICES Description CPT/HCPC Codes Instructions Alpha 1 Proteinase Inhibitors - (Glassia ®, Aralast NP®, Prolastin®, Prolastin - C®, Zemaira®) J0256, J0257 As of 1/1/17 -Request for authorization is provided by Magellan RX for all fully insured groups and individuals. 101 LOW-COST IDEAS FOR WORKSITE WELLNESS 101 Low-cost ideas for worksite wellness The following ideas for worksite wellness can be implemented with limited resources. Many of these ideas have been found to help employees of all physical abilities maintain their health. MODIFIERS PO & PN FOR G0463 CLINIC VISIT SERVICES Page 4 of 5 . rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act (departments that bill the modifier“PO” on
MEMBER DASHBOARD
Log in to the Member Dashboard. Use the Member Dashboard to get real-time views into your claims and benefits for Moda Health and/or Delta Dental members.EBILL - MODA HEALTH
Individuals & Families. If you are a member with an individual/family plan, log in to myModa and look for the eBill tab. Log in to MemberDashboard.
LOGIN - MODA HEALTH
Login. You can find up-to-the-minute medical eligibility, benefits, claims and referral information online seven days a week. Username.Password.
MODA | MEDICARE 2021 Please call Moda Health Customer Service at 503-265-4762 or toll-free at 877-299-9062. TTY users, dial 711. Customer Service is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through March 31. (After March 31, your call will be handled by our automated phone system Saturdays, Sundays and holidays.)MODA HEALTH
PEBB members, learn about Moda Health medical and dental plans. Find a provider, or see if your provider is in our network. See our quarterly magazine, “The Well.” Find out about extra dental benefits, Virtual Visits and more. COMPLAINT AND APPEAL FORM Title: OR AK complaint / grievance / appeal form_Cobranded (updated October 2020) Author: Moda Health / Delta Dental Created Date: 10/5/2020 11:51:40 AM DENTAL BENEFIT TRACKER HELP 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: Select a state. PROCEDURES AND SERVICES Description CPT/HCPC Codes Instructions Alpha 1 Proteinase Inhibitors - (Glassia ®, Aralast NP®, Prolastin®, Prolastin - C®, Zemaira®) J0256, J0257 As of 1/1/17 -Request for authorization is provided by Magellan RX for all fully insured groups and individuals. 101 LOW-COST IDEAS FOR WORKSITE WELLNESS 101 Low-cost ideas for worksite wellness The following ideas for worksite wellness can be implemented with limited resources. Many of these ideas have been found to help employees of all physical abilities maintain their health. MODIFIERS PO & PN FOR G0463 CLINIC VISIT SERVICES Page 4 of 5 . rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act (departments that bill the modifier“PO” on
LOGIN - MODA HEALTH
Login. You can find up-to-the-minute medical eligibility, benefits, claims and referral information online seven days a week. Username.Password.
EMPLOYER DASHBOARD
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CARE PROGRAMS
< Return to overview. Credentialing forms Locum Tenens Form. A practitioner who is new to the Moda Health panel and provides coverage for an absent practitioner or due to practitioner shortage for a period of 90 consecutive calendar days or less is not required to complete the full credentialing process, but rather an expedited process that will approve credentialing for the Locum Tenens REFERRAL AND AUTHORIZATION GUIDELINES Advanced Imaging and Musculoskeletal Services. Authorizations for advanced imaging studies and musculoskeletal services are obtained through eviCore healthcare. Log in to eviCore's Provider Portal at. www.evicore.com. Phone: 844-303-8451. For more information and codes requiring authorization go to www.evicore.com. PROCEDURES AND SERVICES Description CPT/HCPC Codes Instructions Alpha 1 Proteinase Inhibitors - (Glassia ®, Aralast NP®, Prolastin®, Prolastin - C®, Zemaira®) J0256, J0257 As of 1/1/17 -Request for authorization is provided by Magellan RX for all fully insured groups and individuals. OREGON GROUP VISION PLAN WELCOME 1 ModaORVisBk 1-1-2020 (100000016 Opal) SECTION 1. WELCOME . Moda Health is pleased to have been chosen by OEBB as its visionbenefit plan.
TELEHEALTH AND TELEMEDICINE Due to the COVID-19 public health emergency (PHE) this policy has been temporarily supplemented by RPM073, “Telehealth and Telemedicine Expanded Services for COVID-19.” which can be viewed FASLODEX® (FULVESTRANT) Moda Health Plan, Inc. Medical Necessity Criteria Page 4/8 NDC: Faslodex* 250 mg/5 mL single-dose prefilled injections: 00310-0720-xxMODIFIERS 73 & 74
A. General Policy Statement: Effective for claims processed on or after July 1, 2018 (regardless of the date of service on the claim): When planned procedures are discontinued in the ASC or outpatient hospital, the facility fee MODIFIERS 80, 81, 82, AND AS Non-physician assistant at surgery services are to be submitted with modifier -AS appended, not modifier -81. Non-physician assistant at surgery services submitted with modifier -81 appended will Moda Health. Healthcare from your head to your toes.Select a state
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Copyright © 2020 Moda, Inc. All rights reserved. Health plans provided by Moda Health Plan, Inc. Individual medical plans in Alaska provided by Moda Assurance Company. Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon. Dental plans in Alaska provided by Delta Dental of Alaska. This site is meant to help you learn about plans and healthcare for you and your family. This site is subject to change in order to comply with state and federal law, including the Affordable Care Act (ACA) and related regulations, and connectivity with the federal Marketplace. If questions regarding benefits arise, the summary of benefits and coverage document is the master resource.HELLO.
We have exciting news to share. ODS is changing its name to ModaHealth.
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 wayto better health.
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