ALL of the following

• Table of Contents lists a Prior Authorization section and Services Requiring Prior Authorization (see TOC entries).
• Table of Contents references Prior Authorization Limitations and Second Opinion entries.

ALL of the following

• TOC includes Vision Services Claims, Payment of Claims, Notice of Claim and How to Send Us Claims.
• TOC includes Pharmacy Prescription Benefit and Prescription Medication Claims sections.

ALL of the following

• Benefits Available From Other Sources / Coordination of Benefits (COB) is listed in TOC.
• Coordination with Medicare and Third Party Liability entries are in TOC.
• Appeals, External Review, Continuity of Care, Definitions and Complaints are listed in TOC.

ALL of the following

• Care Coordination: Care Coordinators and Case Managers (nurses or behavioral health clinicians) assist members with complex/catastrophic medical situations and coordinate services across levels of care.
• Disease Management & Health Coaching: Health Coaches provide education and support to help members follow provider care plans and self-manage chronic diseases.
• Behavioral Health: Moda Behavioral Health provides specialty services to manage mental health and substance use disorder benefits and assists members in finding Tier 1/2 providers.

ALL of the following

• Members should contact Disease Management, Health Coaching or Behavioral Health Customer Service for program access and details.

ALL of the following

• Plan pays covered services at 100% of the Maximum Plan Allowance (no member cost) and the Plan has no deductible or out-of-pocket maximum.
• When a benefit has an annual or per-year limit, it accrues on a calendar year basis.
• Colonoscopy frequency: one per 10 years starting at age 45+.
• Common visit limits: acupuncture and many general treatment/behavioral services 24 visits per year; some services have a 10 visit lifetime maximum (e.g., biofeedback, ABA).

ALL of the following

• See Benefit Description Section 7 for detailed limits, medical necessity rules and prior authorization requirements (TOC references).

ALL of the following

• Acupuncture: 24 visits per year (Section 7.4.1).
• Applied Behavior Analysis and Biofeedback: 10 visit lifetime maximum where listed (see Sections 7.4.2–7.4.5).
• Dental care special provisions apply for members under age 19 (see Section 7.4.8).
• Supplies related to diabetes covered under Pharmacy benefit (see Section 7.6).
• See Sections 7.4.1–7.4.10 and 7.3.8 for full criteria and medical necessity rules.

ALL of the following

• Providers should verify specific limits and prior authorization requirements via the Member Dashboard or Customer Service as referenced in the document.

ALL of the following

• Dental care for members under age 19: Diagnostic & preventive, minor restorative and other services; frequency limits may apply.
• Orthodontia: covered when medically necessary (see Section 7.4.9).
• Biofeedback: benefit listed with a 10 visit lifetime maximum and limited indication.
• Diabetes supplies: covered under Pharmacy benefits (see Section 7.6).
• Diagnostic procedures (x-ray & lab) are referenced in the schedule; details in Diagnostic Procedures section.

ALL of the following

• See Sections 7.4.3–7.4.10 for full benefit descriptions and medical necessity criteria.

ALL of the following

• Massage therapy: 24 visits per year.
• Outpatient rehabilitation: 45 sessions per year; inpatient rehabilitation/habilitation: 30 days per year.
• Skilled nursing facility care: limits shown (30 days and 60 days values noted in schedule).
• Psychological/neuropsychological testing: 12 hours per year.
• Vision pediatric: one exam and one pair of glasses/contacts per year (under age 19); adult vision: exam annually, frames every 2 years.
• Hearing: hearing exam once per year; one hearing aid per ear once every 3 years.
• Transplant rules: includes donor costs; must use authorized transplant facility and travel/lodging allowance (see schedule).

ALL of the following

• Specialty pharmacy, preferred provider requirements, and vendor routing for vision/hearing are noted; check referenced sections for authorization processes.

ALL of the following

• Benefits payable only when coverage is in effect (enrolled, eligible, premiums paid).
• Services must be medically necessary to diagnose or treat a medical condition or be preventive services to be covered.
• Many services require prior authorization; a full list is maintained on the Moda Health website or Member Dashboard; failure to obtain required prior authorization may result in denial of benefits or penalty (50% up to $2,500 per occurrence as noted elsewhere).
• Authorizations may be time-, service-, frequency-, or provider-specific and limits are described in the authorization letter.
• Emergency services: no prior authorization needed for emergency screening/stabilization; emergency care paid at Tier 1 level worldwide but Tier 1 benefit not available for non-emergency services at Tier 3/out-of-state hospitals.
• Medical transportation: round-trip air transportation requires prior authorization and is limited to 2 round-trips per member per year; reimbursement limited to lowest available commercial airfare.

ALL of the following

• Providers should check Member Dashboard or contact Customer Service to verify prior authorization requirements and limits before providing services that may require authorization.

ALL of the following

• Emergency Room Care: covered worldwide for emergency medical conditions; paid at Tier 1 level; no PA required for emergency screening/stabilization; Tier 1 not available for non-emergency care at Tier 3/out-of-state hospitals.
• Preventive Services: ACA-recommended services covered at no cost when performed by Tier 1 providers; specifics and frequency per ACA guidelines.
• Colorectal Cancer Screening: acceptable tests and frequencies for age 45+ outlined; follow-up colonoscopy covered as part of preventive benefit.
• Contraception and Immunizations: covered per description with applicable limits and ACIP/ACA rules.
• Acupuncture: covered up to annual visit limit and requires prior authorization when medically necessary.
• Anticancer Medication: covered but most require prior authorization and specialty medications must be obtained from designated specialty pharmacy.
• Applied Behavior Analysis (ABA): covered when medically necessary, prior authorized, supervised by certified/licensed behavior analysts with an individualized treatment plan; exclusions apply.
• Behavioral Health: includes outpatient, intensive outpatient, TMS, partial hospitalization and residential care with prior authorization requirements for intensive services.
• Biofeedback: covered only to treat tension or migraine headaches and subject to a lifetime visit limit.
• Clinical Trials: usual care costs covered for approved trials under specified conditions; participation must be prior authorized.

ALL of the following

• Non-emergency services at Tier 3/out-of-state hospitals are not eligible for Tier 1 benefit level; balance billing rules apply as described.

ALL of the following

• Indication: Covered only to treat tension or migraine headaches.
• Limit: Covered visits are subject to a lifetime visit limit (10 visit lifetime maximum noted in Schedule of Benefits).

ALL of the following

• Refer to Section 7.4.5 and the Schedule of Benefits for the specific lifetime visit maximum and prior authorization requirements.

ALL of the following

• Usual care costs for approved clinical trials for cancer or other life-threatening conditions are covered subject to the same cost sharing as non-trial care.
• Eligibility: Covered only if treating physician determines no clear superior non-investigational alternative and available data reasonably expect trial treatment to be at least as effective as alternatives.
• Included costs: prevention, diagnosis, treatment, items necessary to provide investigational service, diagnosis/treatment of complications, certain FDA-approved drugs/devices not paid by manufacturer, administration services, and transportation for patient and one caregiver.
• Exclusions: non-FDA-approved trial drugs/devices, housing/nonclinical expenses, items for data collection only, items excluded under Section 8, items paid by grants or other funding.
• Authorization: Participation in a clinical trial must be prior authorized by Moda Health.

ALL of the following

• Providers should obtain prior authorization and confirm covered trial-related costs with Moda Health before enrollment.

ALL of the following

• Medical necessity: Cochlear implants are covered when medically necessary.
• Authorization: Prior authorization is required.

ALL of the following

• Refer to Section 7.4.?? for detailed criteria and prior authorization process (see TOC references).

ALL of the following

• Age limit: Dental care covered through the end of the month in which member reaches age 19.
• Covered categories include diagnostic, preventive, minor restorative, endodontic, periodontic, oral surgery, prosthodontic, orthodontia (when medically necessary), and other listed services.

ALL of the following

• Diagnostic exams: up to twice per calendar year; full series/panoramic x-ray once every 5 years; bitewings once per 6 months.
• Prophylaxis: twice per calendar year (additional cleanings may be eligible if pregnant or diabetic).
• Prefabricated stainless steel crowns for under age 15: one per tooth in any 5-year period.
• Orthodontia: covered only when medically necessary for disabling malocclusion, cleft palate or severe craniofacial defects impacting function; payment schedule described in policy.

ALL of the following

• Certain diagnostic services (e.g., TMJ films, cone beam CT) and services not listed are not covered; implants and implant-related services have separate criteria and timing.
• Teledentistry: virtual dental visits may be provided but are included in overall fees and not covered as separate benefit.

ALL of the following

• Qualification: Injury must be accidental caused by a foreign object or acute trauma (biting/chewing food is not accidental injury).
• Timelines: Diagnosis within 6 months of injury and treatment begins within 12 months of injury.
• Scope: Treatment must be medically necessary, provided while covered, and limited to restoring teeth to a functional state; implants and implant-related services are not covered.

ALL of the following

• Providers should document timing of diagnosis and initiation of treatment and confirm coverage eligibility at time of service.

ALL of the following

• Insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) are covered under the Pharmacy benefit when purchased at a pharmacy with a valid prescription and using a preferred manufacturer.
• Insulin pumps may be covered under DME benefit if not obtained from a pharmacy.
• Covered diabetes management services include HbA1c testing, kidney disease checks, annual dilated eye exam/retinal imaging, outpatient self-management education, and medical nutrition therapy when prescribed.

ALL of the following

• Ensure prescriptions for diabetic supplies indicate preferred manufacturer and advise members to use in-network pharmacies to receive pharmacy benefit coverage.

ALL of the following

• Services must be for treatment of a medical or behavioral health condition (medical purpose required).
• Included diagnostics: x-rays, lab tests, standard and advanced imaging, psychological and neuropsychological testing, and other diagnostic procedures.
• Most advanced imaging services (MRI, MRA, CT, PET, nuclear medicine, cardiac imaging) must be prior authorized; full list on Moda Health website or Customer Service.

ALL of the following

• Providers should obtain prior authorization for advanced imaging per Section 6.1.1 and confirm via Member Dashboard.

ALL of the following

• Definition: DME includes equipment and related supplies for home use designed for repeated use to manage a medical condition.
• Examples: CPAP, certain glasses/contact lenses for specific diagnoses, insulin pumps, hospital beds, orthotics, oxygen, prosthetics, wheelchairs/scooters.
• Rental and purchase: rental charges covered up to purchase price for most DME; replacement/repair covered if not abused and within warranty conditions.
• Prior authorization: some DME and supplies require prior authorization; full list on Moda Health website or Customer Service.

ALL of the following

• Excluded items include those primarily for comfort/cosmetic purposes, wigs, dental appliances/braces, most therapeutic devices (except TENS), incontinence supplies, hearing aids/eyeglasses/contact lenses except as covered elsewhere.
• Providers are encouraged to use preferred DME providers listed on Member Dashboard to potentially reduce member cost sharing.

ALL of the following

• Eligibility: Covered when the patient is previously treated by the provider (established patient) and the e-visit is medically necessary for a covered condition.

ALL of the following

• Providers should ensure the patient is an established patient and document medical necessity for billing e-visits.

ALL of the following

• Procedures must be performed by a qualified professional provider.
• Prior authorization is required for surgical procedures.
• Treatment plan must meet medical necessity criteria.

ALL of the following

• Mental health services and hormone therapy (including puberty suppression for adolescents).
• Surgical procedures such as breast/chest surgery, gonadectomy, genital reconstruction and facial surgery (subject to prior authorization and medical necessity criteria).

ALL of the following

• Providers must obtain prior authorization for surgical gender-affirming procedures and document medical necessity per policy criteria.

ALL of the following

• Outpatient health education services that manage a covered medical condition are covered (examples: tobacco cessation, diabetes education, asthma education, pain management, childbirth/newborn parenting training).

ALL of the following

• Providers should document the condition being managed and medical necessity for health education services.

ALL of the following

• Procedures must be performed by a qualified professional provider.
• Prior authorization is required for surgical procedures.
• Treatment plan must meet medical necessity criteria.
• Covered services may include mental health, hormone therapy (including puberty suppression for adolescents), and surgical procedures such as breast/chest surgery, gonadectomy, genital reconstruction, and facial surgery.

ALL of the following

• Obtain prior authorization and ensure documentation supports medical necessity and provider qualifications.

ALL of the following

• Home healthcare covered if member is homebound, services are medically necessary, and ordered by the treating physician.
• Visits must be provided by qualified professional providers (RN/LPN, PT/OT/SLP, licensed social worker); home health aides do not qualify as home health service providers.
• Home health visits subject to an annual limit for RN/LPN services; other providers limited to one visit per day.

ALL of the following

• Hospice services covered when included in a hospice treatment plan for terminally ill members not receiving curative treatment; covered hospice providers listed in policy.
• Respite care covered if member needs continuous assistance, must be arranged by attending provider, prior authorized and limited to a set number of hours; non-professional providers may be covered with prior approval.
• Exclusions: hospice services provided to others than the terminally ill member and services not in the hospice treatment plan are not covered.

ALL of the following

• Providers must order home healthcare and obtain prior authorization where required; document homebound status and physician orders.

ALL of the following

• Inpatient hospital care covered when medically necessary; covered items include hospital room, isolation care, ICU, facility charges for outpatient surgery and other medically necessary hospital services and supplies.
• Take-home prescription drugs limited to a 3-day supply at the same benefit level as hospitalization.
• General anesthesia and related facility charges for dental procedures in a hospital or ambulatory surgical center are covered when medically necessary and prior authorized for specified patient groups (children under 7, disabled, or those at undue risk in dental office).

ALL of the following

• Providers should ensure prior authorization for scheduled inpatient admissions per Section 6.1.1 and document medical necessity for hospital-level care.

ALL of the following

• Medically necessary infusion therapy services and supplies are covered including solutions, compounding, DME, ancillary supplies, nursing services and lab testing to monitor therapy.
• Provider must obtain prior authorization for infusion therapy; preferred medication suppliers and preferred treatment centers may be available for some medications.
• Medications administered in a provider office, treatment/infusion center or home infusion are covered at the same benefit level as supplies and appliances; self-administered medications are not covered under this benefit.

ALL of the following

• Providers should request prior authorization for infusion therapy and coordinate with Pharmacy Customer Service for preferred suppliers.

ALL of the following

• Covered dialysis expenses include treatment planning, professional services for administration/supervision, and treatments including therapist, facility and equipment charges.
• Members with end-stage renal disease (ESRD) should be enrolled in Medicare Part B to receive the best benefit.

ALL of the following

• Providers should coordinate benefits with Medicare Part B for ESRD members to optimize coverage.

ALL of the following

• Nonprescription elemental enteral formula for home use covered if medically necessary and ordered by physician as sole or essential source of nutrition.
• Nutritional therapy: assessment and individualized counseling covered; ACA-required preventive nutritional therapy covered at no cost for specified groups.
• Phenylketonuria: formulas necessary for treatment are covered.
• Podiatry: covered to diagnose and treat a specific current problem; routine podiatry not covered unless medically required (e.g., diabetes).
• Pre-admission testing: covered when ordered by a professional provider.

ALL of the following

• Providers should document medical necessity and physician orders for these services and check prior authorization requirements where applicable.

ALL of the following

• Podiatry services are covered to diagnose and treat a specific current problem; routine podiatry services are not covered unless medically required (e.g., diabetes).

ALL of the following

• Prior authorization may be required for certain podiatry procedures; confirm via Member Dashboard.

ALL of the following

• Pre-admission testing is covered when ordered by a professional provider.

ALL of the following

• Providers should include orders when submitting claims for pre-admission testing and check authorizations if required.

ALL of the following

• Psychological or neuropsychological testing and evaluation are covered, including interpretation and report preparation necessary to prescribe an appropriate treatment plan.

ALL of the following

• Prior authorization and documentation of medical necessity may be required for some testing; see Section 7.4.30.

ALL of the following

• Rehabilitative services must begin within 24 months of onset of condition and be part of a physician's formal written program to improve and restore lost function.
• Outpatient rehabilitation/habilitation and chronic pain care are subject to annual visit limits (e.g., outpatient rehab 45 sessions per year); limits apply separately to rehabilitative and habilitative services.
• Services to treat intractable or chronic pain are subject to the annual limit; benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition.

ALL of the following

• Providers should obtain prior authorization where required and document therapy start date relative to condition onset.

ALL of the following

• A skilled nursing facility provides inpatient rehabilitative care and 24-hour nursing; covered days are limited as shown in the Schedule of Benefits.
• Covered expenses limited to the daily service rate for a semi-private hospital room.

ALL of the following

• Charges not covered include admissions before coverage, care mainly for cognitive decline/dementia, routine nursing care, non-medical self-help, personal hygiene or custodial care.

ALL of the following

• Verify covered day limits and medical necessity for SNF admissions; prior authorization may be required.

ALL of the following

• Spinal and other manipulations are covered up to an annual visit limit for treatment of a medical condition; services at a manipulation visit (office visit, x-rays, PT) are billed under standard benefits.
• Spinal manipulations must be prior authorized.

ALL of the following

• Providers should obtain prior authorization and document medical necessity for manipulation services.

ALL of the following

• Surgery is covered when medically necessary; benefit includes primary surgeon, assistant surgeon, anesthesiologist/CRNA, surgical supplies and facility charges.
• MPA for assistant surgeon is 20% of physician's MPA (or 10% of PA/CRNA MPA).
• Eligible office-based surgery is covered subject to appropriate prior authorization; reconstructive surgery must be medically necessary and prior authorized.

ALL of the following

• Cosmetic surgery is not covered except reconstructive surgery that is medically necessary; surgery for breast enhancement not covered except to treat gender dysphoria or post-mastectomy reconstruction per policy rules.

ALL of the following

• Obtain prior authorization for non-emergency inpatient admissions and office-based surgeries as required (see Section 6.1.1).

ALL of the following

• TMJ-related surgical procedures and splints require prior authorization and are covered only when medically necessary for problems such as pain or inability to chew properly or severe acute trauma.
• Orthodontia services and treatment of related dental diseases or injuries are not covered under TMJ section.

ALL of the following

• Providers should document medical necessity and obtain prior authorization for TMJ surgeries and related appliances.

ALL of the following

• Administrative services for therapeutic injections (e.g., allergy shots) are covered when given in a professional provider's office; when self-administered alternatives exist, administrative services by provider are not covered.
• Vitamin and mineral injections are not covered unless medically necessary to treat a specific medical condition.

ALL of the following

• Document necessity for injections and check whether administration charges are covered under the plan.

ALL of the following

• Covered expenses include treatment planning and simulation, professional services for administration and supervision, and treatments including therapist, facility and equipment charges.

ALL of the following

• Prior authorization may be required for some therapeutic radiology services; confirm per Section 6.1.1.

ALL of the following

• Transplants covered when medically necessary and not experimental; prior authorization should be obtained as soon as possible after identification as a transplant candidate and must be in writing from Moda Health.
• Transplant procedures must be done at a Center of Excellence unless unavailable; donor costs are covered per specified conditions and travel/housing expenses for recipient and caregiver may be covered up to limits if recipient lives more than 50 miles from Center of Excellence.
• Certain transplant-related drugs and chemotherapy exclusions described; outpatient transplant-related meds paid under Pharmacy benefit.

ALL of the following

• Obtain written prior authorization and coordinate use of authorized transplant facility and preferred vendors for travel/lodging as applicable.

ALL of the following

• Virtual care (telehealth) is covered when services can be safely and effectively provided via live interactive audio/visual/data communication by a provider licensed in Alaska or referred by such a provider and when privacy/security standards are met.

ALL of the following

• Providers must be licensed in Alaska and ensure technology meets state/federal privacy and security standards.

ALL of the following

• Pregnancy care, childbirth and related conditions are covered when provided by a professional provider; maternity services are billed as a global charge unless specified diagnostic services are reimbursed separately.
• Special Rights Upon Childbirth guarantee hospital stay up to 48 hours (vaginal) or 96 hours (cesarean) without prior authorization.
• Take-home prescription drugs limited to a 3-day supply at the same benefit level as hospitalization.

ALL of the following

• Providers should follow global billing rules and document services that are reimbursed separately; no PA needed for hospital stay up to specified postpartum limits.

ALL of the following

• Elective abortions are covered under the Plan.

ALL of the following

• Providers should bill per applicable sections and document medical necessity when indicated.

ALL of the following

• Comprehensive lactation support and counseling covered during pregnancy and breastfeeding; breast pump purchase or rental covered (MPA applies for retail purchase); hospital-grade pumps covered when medically necessary.
• Extra items such as ice packs or coolers are not covered.

ALL of the following

• Providers should document medical necessity for hospital-grade pumps; members buying pumps at retail are subject to MPA.

ALL of the following

• Circumcision within 3 months of birth is covered without prior authorization.
• Circumcision after age 3 months must be medically necessary and prior authorized.

ALL of the following

• Providers should confirm age and prior authorization requirements for circumcision performed after 3 months of age.

ALL of the following

• Breastfeeding support: lactation counseling and breast pump purchase/rental covered; MPA applies for retail purchases; hospital-grade pumps covered when medically necessary.
• Circumcision: covered without PA if within 3 months of birth; after 3 months requires medical necessity and prior authorization.
• Maternity diagnostics: some procedures related to maternity care may require prior authorization; full list on Moda Health website or Customer Service.
• Pharmacy supplies: insulin and diabetic supplies covered under Pharmacy benefit when obtained at a pharmacy with prescription and preferred manufacturer; specialty meds and step therapy rules apply.
• Formulary exceptions: members may request exceptions based on medical necessity with specified timelines for decisions.

ALL of the following

• Specialty medications often must be obtained from Moda-designated specialty pharmacy; VSP handles vision vendor authorizations; hearing vendor handles hearing benefit authorization.

ALL of the following

• Pediatric vision (under 19): one complete well-vision exam and one pair of eyeglasses and frames or contact lenses annually through end of month turning 19; contact lenses require minimum supply per type.
• Adult vision (19+): one complete eye exam annually; one pair of frames every 2 years; one pair of corrective lenses annually (elective contacts in lieu of eyeglasses).
• Hearing: one audiological exam annually; one hearing aid per ear once every 3 years; otological exam every 2 years and prescriptive requirements apply.
• Vendor routing and authorizations: VSP provides benefit authorization to Tier 1/2 vision providers; hearing vendor provides highest benefit when using Tier 1 audiologist; some services may require prior authorization.

ALL of the following

• Certain vision/hearing services and supplies are excluded per Section 8; if services obtained from non-Tier 1/2 providers or without authorization, member may be responsible for payment and reimbursement limited to Tier 3 allowances.