Prior authorization required for listed services (SECTION 6)

Certain services require prior authorization as described in SECTION 6 and 6.1.1; prior authorization limitations are described in 6.1.2. When a service requires authorization, ask your provider to contact Moda Health for prior authorization before the service is provided.

• Prior authorization is used to ensure treatments are safe and cost-effective and is evaluated using evidence-based criteria (SECTION 6).
• Authorization letters will describe any limits, time periods, or provider requirements (6.1.2).

Verify prior authorization need via Member Dashboard

Check the Member Dashboard before rendering care to determine whether a service or supply must be prior authorized and to view medication cost estimates, tiers, and authorization status.

• Member Dashboard shows if a service or supply must be prior authorized and provides prescription price/benefit tier information.
• A full list of services requiring prior authorization is available on the Moda Health website/Member Dashboard.

Consult Section 6 for services that require prior authorization

Prior authorization may be required for some services — providers should consult Section 6 (6.1.1) and the Moda Health website/Member Dashboard for the full list of services that must be authorized.

• Section 6.1.1 lists categories of services that may require authorization (inpatient, outpatient, rehabilitation, diagnostic services, etc.).
• Ask your provider to contact Moda Health for prior authorization before the service.

Follow medication/provider/setting limits and specialty pharmacy rules

Some medications may be limited to specific providers or settings and may be covered only under the specialty pharmacy benefit; prior authorization and use of preferred providers or settings may be required.

• Section 3 notes some medications are limited to certain providers/settings and certain medications are covered under specialty pharmacy.
• Section 6.1.2 explains authorization may require use of a preferred treatment center or provider for coverage at a higher benefit level.
• Infusion therapy authorizations may be limited to preferred medication suppliers or home infusion providers (7.4.18).

Authorization required for nutritional therapy for eating disorders

Nutritional therapy for eating disorders requires authorization; services must be authorized after the first five visits.

• Schedule of Benefits and Section 3 indicate nutritional therapy for eating disorders must be authorized.
• Authorization is required after the member's first five visits.

Prior authorization for non-Moda-designated specialty pharmacies

Most specialty medications must be obtained from a Moda-designated specialty pharmacy; prior authorization is required to obtain non-Moda-designated specialty pharmacy dispensing for nonpreferred specialty medications.

• Section 3 states prior authorization is required for non-Moda-designated specialty pharmacies.
• Section 7.6.5 explains most specialty medications require prior authorization and that non-Moda-designated specialty pharmacy purchases require prior authorization.

Prior authorization for anticancer medications from non-designated pharmacies

Anticancer specialty medications must be obtained from Moda's designated specialty pharmacy or the provider must obtain prior authorization to use a non-designated pharmacy.

• Section 7.4.1 requires most anticancer medications be prior authorized and obtained from the designated specialty pharmacy or prior authorization obtained for a non-designated pharmacy.
• Section 3 reiterates prior authorization is required for non-Moda-designated pharmacies for anticancer medications.

Obtain prior authorization for many inpatient/outpatient/rehab/diagnostic/infusion services

Many inpatient, outpatient, rehabilitation, diagnostic (including advanced imaging), infusion therapy services, and certain medications require prior authorization — providers must contact Moda Health before providing these services.

• Section 6.1.1 lists inpatient services, outpatient services, rehabilitation and diagnostic services (including imaging) among services that may require authorization.
• Providers must get prior authorization for most advanced imaging services (7.4.8).
• Infusion therapy requires prior authorization and may be limited to specified suppliers/settings (7.4.18).

Obtain out-of-network prior authorization or risk penalties/balance billing

When using an out-of-network provider the provider must obtain prior authorization; failure to obtain required authorization can trigger a prior authorization penalty and may leave the member responsible for charges above the MPA.

• Section 6.1 requires you to ensure your provider contacts Moda for prior authorization when using an out-of-network provider; otherwise a penalty applies.
• If you do not use an in-network provider you may have to pay amounts over the maximum plan allowance (MPA).
• Balance billing can occur when in-network facility uses out-of-network professionals and the member may owe amounts above the MPA (Section 5).

Prior authorization required for many outpatient/inpatient services and certain meds/ABA

Most outpatient services and all nonemergency inpatient and residential care must be prior authorized; additionally, most anticancer medications and ABA services require prior authorization.

• Section 7.4 states many outpatient services and all nonemergency inpatient and residential care must be prior authorized.
• Most anticancer medications need prior authorization (7.4.1).
• ABA services are covered only when prior authorized (7.4.2).

Prior authorization required for ABA services

Applied Behavior Analysis (ABA) services for autism spectrum disorder are covered only when prior authorized; do not bill for services that lack prior authorization.

• Section 7.4.2 explicitly states ABA services must be prior authorized.
• Examples of non-covered ABA-related services are provided; ensure submitted services meet coverage criteria.

Prior authorization for intensive behavioral services (IOP, ACT, STAR, TMS)

Intensive behavioral services — including intensive outpatient mental health, ACT, STAR programs and transcranial magnetic stimulation (TMS) — must be prior authorized before services begin.

• Section 7.4.3 notes intensive outpatient mental health treatment, ACT, STAR and TMS require prior authorization.
• Confirm authorization covers the required hours/intensity (e.g., intensive outpatient mental health = 3+ hours/week).

Obtain prior authorization for advanced imaging/diagnostics

Most advanced imaging and many diagnostic procedures require prior authorization; providers must obtain authorization for most advanced imaging (MRI/MRA, CT, PET, nuclear medicine, cardiac imaging).

• Section 7.4.8 and Section 6.1 indicate providers must get prior authorization for most advanced imaging services.
• A full list of diagnostic procedures requiring prior authorization is available on the Moda Health website or via Customer Service.

Prior authorization for clinical trial participation

Participation in clinical trials must be prior authorized and is limited to approved trials that meet specified funding or regulatory criteria.

• Section 7.4.6 requires prior authorization for participation in clinical trials and limits coverage to trials funded or supported by specified federal agencies or conducted as IND/IDE/BLA or exempt trials.
• Investigational items provided only for data collection are not covered.

Prior authorization for gender-affirming surgery (age >18)

Surgical gender-affirming procedures for members over age 18 require prior authorization and must meet medical necessity criteria.

• Section 7.4.11 states prior authorization is required for surgical procedures related to gender-affirming treatment and members must be over age 18.
• Treatment plan must meet medical necessity criteria and procedures must be by a qualified provider.

Prior authorization required for infusion therapy and certain hospice/respite services

Infusion therapy and respite care require prior authorization; when authorization is limited to a specific supplier or setting, services from other suppliers may not be covered.

• Section 7.4.18 specifies your provider must get prior authorization for infusion therapy and that authorization may require use of a preferred supplier or setting.
• Section 7.4.14/Respite Care requires respite be arranged by the attending provider and prior authorized.

Prior authorization for reconstructive surgery

All reconstructive procedures must be medically necessary and prior authorized; cosmetic procedures are not covered.

• Section 7.4.30 states reconstructive surgery must be medically necessary and prior authorized or benefits will not be paid.
• Cosmetic surgery is explicitly excluded.

Prior authorization required for transplants — obtain promptly

Obtain prior authorization for transplants as soon as possible after a patient is identified as a candidate; donor-related expenses and travel/housing have specific coverage limits.

• Section 7.4.33 instructs providers to obtain prior authorization as soon as possible after transplant candidacy is identified.
• Travel and housing for recipient and one caregiver are covered up to a per-transplant maximum (Section 3/7.4.33).

Prior authorization for vision services (VSP handles in-network authorizations)

Some vision services may require prior authorization; in-network VSP providers obtain benefit authorization directly from VSP — providers should coordinate authorization with VSP for in-network vision care.

• Section 7.4.35 notes some vision services require prior authorization and VSP handles benefit authorization for in-network providers.
• Member ID card and eligibility should be verified before billing.

Prior authorization required for many prescription and specialty medications

Certain prescription medications and many specialty medications require prior authorization; specialty medications must be obtained from a Moda-designated specialty pharmacy unless prior authorization permits another pharmacy.

• Section 7.6 states certain medications and quantities may need prior authorization and specialty medications must be obtained from a Moda-designated specialty pharmacy.
• Buying specialty meds at a non-Moda-designated specialty pharmacy requires prior authorization (7.6.5/Section 3).

Obtain documentation and prior authorization for reconstructive/gender-affirming exceptions

Exceptions for reconstructive or gender-affirming services require documentation of medical necessity and prior authorization per plan rules.

• Section 7.4.30 and exclusion language state reconstructive or gender-affirming surgery may be covered if medically necessary and not excluded, with appropriate documentation.
• Certain excluded procedures may be covered only when documentation supports an exception (e.g., obesity comorbidity, orthognathic for accidental injury).

Prior authorization and documentation required for exception cases (orthognathic, obesity comorbidity, etc.)

For some excluded procedures (e.g., orthognathic surgery, obesity-related comorbidity treatments), prior authorization and supporting documentation demonstrating medical necessity are required to consider coverage exceptions.

• Orthognathic surgery is excluded except when medically necessary to repair accidental injury or treat cancer (chunk 245).
• Services to treat medical conditions caused by obesity may be covered while treatments to address obesity directly are excluded (chunk 243).
• Routine foot care is excluded unless the member's medical condition (such as diabetes) requires it (chunk 252).

Pre-coverage admissions not covered except for expenses on/after effective date

Admissions that began before the member's coverage start date are not covered except for covered expenses incurred on or after the policy effective date; providers should verify coverage effective dates prior to services.

• Section 10/271 states services for admissions that began before coverage starts are not covered except for expenses incurred on or after the effective date.
• Section 7.1 reiterates benefits are payable only when coverage is in effect.

Step therapy (pharmacy) — document Step 1 trials

Step therapy is defined under the Pharmacy Prescription Benefit (Section 7.6); when a medication is in the step therapy program the prescriber must document Step 1 medication trials before a Step 2 medication will be covered.

• Section 7.6 defines step therapy processes and rules.
• If a Step 2 prescription is submitted before trying Step 1, it will not be covered and the provider must prescribe the Step 1 medication unless an exception applies.

Use Member Dashboard Prescription Price check for step therapy and tier info

Use the Member Dashboard Prescription Price check tool to view medication tiers, cost estimates, and indicators of step therapy or formulary requirements prior to prescribing or dispensing.

• Member Dashboard provides medication cost estimates and benefit tier information (Prescription Price check).
• Tool can indicate whether a medication is subject to step therapy or prior authorization.

Pharmacy network (Navitus) manages step therapy and specialty rules

Pharmacy benefits, including step therapy rules and specialty pharmacy controls, are administered through the Navitus pharmacy network; coordinate with Navitus for pharmacy management and prior authorization processes.

• Section 2/3 identifies Navitus as the pharmacy network.
• Section 7.6.5 and related sections describe specialty controls that are managed through the pharmacy network and Member Dashboard.

Follow medication provider/setting limits and specialty pharmacy sourcing

Some medications may be limited to specific providers or settings and the specialty pharmacy benefit applies to certain medications; providers must follow those sourcing and setting requirements when obtaining medications.

• The Schedule of Benefits notes some medications are limited to certain providers or settings and certain medications are covered under specialty pharmacy.
• Section 7.6.5 explains many specialty medications must come from the designated specialty pharmacy.

Designated specialty pharmacy sourcing required for many specialty meds

Certain specialty medications must be obtained from a Moda-designated specialty pharmacy; buying at a non-designated specialty pharmacy requires prior authorization and may be denied otherwise.

• Section 7.6.5: most specialty medications must be obtained from a Moda-designated specialty pharmacy and require prior authorization for non-designated pharmacies.
• Section 3 (Schedule) notes prior authorization required for non-Moda-designated specialty pharmacies.

Use Moda-designated mail order/specialty pharmacies for designated tiers

Some pharmacy tiers (Value/Select and similar) require use of Moda-designated mail order or specialty pharmacies for 90-day supplies or mail-order fulfillment; providers should direct members to designated channels when applicable.

• Section 3 indicates mail order and certain tiers must use Moda-designated mail order or pharmacies for 90-day supplies.
• Providers and members should confirm eligibility for mail-order and designated pharmacy channels via Member Dashboard.

Authorization may require preferred centers/providers and impose limits

Prior authorization may require use of preferred treatment centers or providers for higher benefit levels and may limit number, amount, frequency, or time period of authorized services; authorization letters will state applicable limits.

• Section 6.1.2 lists prior authorization limitations including time validity, treatment limits, and requirement to use preferred providers for higher benefits.
• Any limits will be described in the authorization letter sent to you and the provider.

Anticancer medication program enrollment and specialty pharmacy controls

Some anticancer medications may require enrollment in specific programs and specialty anticancer medications must be obtained from the designated specialty pharmacy or prior authorization obtained for non-designated pharmacies.

• Section 7.4.1 states some anticancer medications require program enrollment to ensure appropriate use or reduce cost.
• Specialty anticancer medications must come from the designated specialty pharmacy or have prior authorization for non-designated dispensing.

Pharmacy vs DME sourcing for insulin and diabetes supplies

Insulin and diabetic supplies are covered under the pharmacy benefit when purchased from a pharmacy with a valid prescription and using a preferred manufacturer; insulin pumps obtained outside the pharmacy benefit may be processed under DME rules.

• Section 7.4.7 confirms insulin and diabetic supplies are covered under the pharmacy benefit with prescription and preferred manufacturer.
• Insulin pumps may be covered under the DME benefit if not obtained from a pharmacy.

Use preferred supplier/setting for certain medications to ensure coverage

Members may be required to use a preferred medication supplier, home infusion provider, or provider office infusion for certain medications; when authorization is limited to specified suppliers or settings, services from others may not be covered.

• Section 7.4.18 indicates you may have to use a preferred medication supplier or home infusion provider for some infusion medications.
• Section 6.1.2 notes prior authorization may require use of a preferred treatment center or provider for coverage at a higher benefit level.

Do not bill for in-office injection administration when self-administered alternative exists

Administrative services for in-office therapeutic injections are not covered when similar results can be achieved with self-administered medications at home; bill accordingly under medical or pharmacy benefits.

• Section 7.4.31 states administrative services for injections are not covered when self-administered alternatives exist.
• Section 7.6/254 clarifies self-administered medications obtained from a physician's office are excluded from pharmacy benefits and must be billed appropriately.

Step therapy: document Step 1 trials or documented exception

When a medication is in the step therapy program, the prescriber must ensure the member has tried required Step 1 medications before prescribing Step 2; document exceptions if Step 1 is ineffective, harmful, or not equivalent.

• Section 7.6.7 requires trial of Step 1 medications before Step 2 will be covered; prescriptions submitted out of order will not be covered.
• Exceptions are allowed if Step 1 is ineffective, harmful, or not providing equivalent results, and must be documented.

Step therapy specifics not detailed here — consult Pharmacy sections

No specific step therapy guidance is specified in this segment beyond Section 7.6; consult the Pharmacy Prescription Benefit and Member Dashboard for program details.

• Section 7.6 defines step therapy and related processes.
• Use the Member Dashboard or Pharmacy Customer Service for program specifics.

Self-administered medications obtained from provider office excluded from pharmacy/anticancer benefit

Self-administered oral and injectable medications obtained directly from a physician's office rather than through pharmacy benefits are excluded from the pharmacy/anticancer benefits; bill and source these items according to the appropriate medical benefit rules.

• Section 7.6.6/254 states self-administered medications obtained from a physician's office are excluded from pharmacy/anticancer benefits.
• Specialty and anticancer sourcing requirements (Section 3/7.4.1) may affect coverage and billing.

Contact Customer Service or Member Dashboard for questions and authorizations

For questions or to access policy information, providers and members should use the contact numbers in section 2.1 or the Member Dashboard; Customer Service and Behavioral Health Pharmacy contacts are available for specialty assistance.

• Section 1 directs users to Member Dashboard and section 2.1 contact numbers for policy questions.
• Behavioral Health and Pharmacy Customer Service contacts are listed for specialty inquiries.

Verify member ID card at visits to confirm coverage and network

Ask members to present their Moda ID card at each visit so providers can verify membership, network and benefit channels before rendering services.

• Section 2.2 indicates ID cards list member ID number and provider network; providers should confirm network and direct members to Member Dashboard to request replacements.

Verify membership/network via ID card and Member Dashboard before services

Providers should confirm membership and network using the member's ID card and Member Dashboard before scheduling services subject to prior authorization or network-specific sourcing.

• Member ID cards show network and should be presented at visits (Section 2.2).
• Member Dashboard can be used to confirm whether a service requires prior authorization.

Consult Sections 7.4.14–7.4.23 for network/setting restrictions and documentation

Consult Sections 7.4.14–7.4.23 for additional network, provider, or setting restrictions and documentation requirements that may apply to specific services.

• Schedule of Benefits references Sections 7.4.14–7.4.23 for detailed limits and provider/setting restrictions.
• Section 6.1.2 notes any limits or preferred-provider requirements will be described in authorization letters.

Authorization required after first 5 visits for nutritional therapy (eating disorders)

Authorization is required after the first five visits for nutritional therapy for eating disorders; providers should request authorization promptly to avoid coverage issues.

• Schedule of Benefits and Section 3 explicitly state authorization is required after the first five visits.
• Obtain prior authorization per Section 6 to ensure continued coverage.

Authorization letters describe limits; emergency admissions must be authorized within 48 hours

Authorization letters will describe any limits, time periods, or provider requirements; emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).

• Section 6.1.2 indicates limits/requirements for authorized services are described in the authorization letter.
• Section 6 requires emergency admissions be authorized within 48 hours after admission (or as soon as reasonably possible).

Contact Customer Service and provide documentation for out-of-area child assignments

For out-of-area enrolled children (full-time student or under a QMCSO), the member must contact Customer Service and provide documentation such as school enrollment or address to arrange out-of-area network assignment.

• Section 5.1.2 requires contacting Customer Service and supplying documentation for out-of-area child assignment.
• The child is assigned to the out-of-area network on the first day of the month after documentation is received.

Authorization letters and timing for emergency admission authorization

Authorization letters will specify any limits, time periods, or provider requirements; emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).

• Limits and requirements that apply to authorized services are described in the authorization letter (6.1.2).
• Emergency admissions must be authorized within 48 hours after admission (Section 6).

Notify PCP after emergency care; facility vs professional billing notes

Let the member's PCP know as soon as possible about any emergency care received; facility emergency services cover facility charges while professional fees may be billed separately under inpatient or outpatient benefits.

• Section 7.2.2 instructs members to notify their PCP as soon as possible after emergency care.
• Facility emergency services cover supplies, labs and other facility charges; professional fees may be billed separately.

Member must authorize DME supplier to provide records if requested

If requested, the member must authorize DME suppliers to provide equipment order information and records needed to approve claim payment; providers should obtain member authorization to release such records when required.

• Section 7.4.9 states that if Moda asks, the member must authorize the DME supplier to give Moda information about the equipment order and records needed to approve a claim.

Hospice treatment plan required and periodically reviewed

Hospice care requires a written hospice treatment plan established and periodically reviewed by the treating provider certifying the member is terminally ill; providers must maintain and submit the treatment plan when requested.

• Section 7.4.14 requires hospice services be part of a hospice treatment plan with provider certification that the member is terminally ill.
• The plan must describe services and supplies the approved hospice will provide and be periodically reviewed.

Submit hospice plan and certification for authorization and periodic review

Hospice care must be part of a written hospice treatment plan periodically reviewed and must include provider certification that the member is terminally ill; submit the plan for authorization and ongoing review as requested.

• Section 7.4.14 specifies the hospice treatment plan requirements and provider certification.
• Hospice home care services must be from an approved hospice and documented in the plan.

Document home healthcare order and member homebound status

Home healthcare must be medically necessary, ordered by the treating practitioner or specialist, and the member must meet homebound criteria; providers should document homebound status and physician orders.

• Section 7.4.13 requires home healthcare to be ordered by the treating practitioner and for the member to be homebound as defined.
• Visits must be intermittent and provided by licensed professionals; home health aides are not covered under the home healthcare benefit.

Provide written therapy treatment plan documenting medical necessity and improvement intent

Therapy services must be part of a written treatment plan documenting medical necessity and intent to improve or restore lost function; providers should maintain and submit treatment plans to support authorization and claims.

• Section 7.4.20 requires therapies be part of a written treatment plan demonstrating medical necessity and intent to improve function.
• Outpatient rehabilitative services are short term and expected to show improvement; maintenance therapy without documented improvement is not covered.

Document donor costs and submit travel/housing receipts for transplant coverage

Donor-related transplant costs are covered when the recipient or self-donor is enrolled; document donor expenses (removal, preservation, transport) and submit travel/housing receipts subject to per-transplant maximums.

• Section 7.4.33 details covered donor costs and that donor costs are covered when recipient or self-donor is enrolled; if donor or recipient is not enrolled, donor costs may not be covered.
• Travel and housing for recipient and one caregiver are covered up to a maximum per transplant (Section 3).

Provide formulary exception documentation and expect 72/24-hour decision timelines

Formulary exception requests must include the prescribing provider's contact information and clinical rationale showing trials, intolerance, harm, or lack of equivalent effect of formulary alternatives; expect a decision within 72 hours (24 hours if urgent).

• Section 7.6 requires documentation that formulary medications were tried at the right dose/duration and were ineffective or not tolerated, or that the requested medication is not expected to be equivalent.
• Formulary exception decisions are made within 72 hours or 24 hours if urgent.

Formulary exception timelines: 72 hours standard, 24 hours urgent

Formulary exception decisions are issued within 72 hours for standard requests and within 24 hours for urgent requests; providers should indicate urgency and submit supporting clinical information.

• Section 7.6 states decision timelines for formulary exceptions: 72 hours standard, 24 hours if urgent.
• Include prescribing provider contact and clinical information to support the request.

Submit documentation to support exceptions when exclusions overlap coverage

When services overlap exclusion categories or an exclusion would otherwise apply, providers must submit documentation demonstrating medical necessity and applicability of an exception (e.g., reconstructive surgery versus cosmetic).

• Section 7 and Section 8 exclusions note that exclusions may be reversed when documentation supports exceptions (e.g., orthognathic for accidental injury).
• Documentation should clearly justify why the service meets medical necessity criteria and any referenced exceptions.

Document medical necessity for exception-based coverage (orthognathic, obesity comorbidity, etc.)

For exception-based coverage (e.g., orthognathic surgery for accidental injury, obesity-related comorbidity treatment), providers must supply documentation supporting medical necessity and the exception conditions identified in the policy.

• Section 8 and related sections list exclusions and the specific exceptions; providers must document criteria that justify coverage under an exception.
• Routine foot care is excluded unless required by a medical condition such as diabetes (chunk 252).

Hearing aids ordered before coverage ends must be received ≤90 days after policy end

Hearing aids ordered before coverage ends must be received by the member within 90 days after the policy ends to be covered; providers should document order dates and delivery receipts accordingly.

• Section 10/270 specifies covered hearing aids ordered before coverage ends must be received within 90 days after policy termination.

Document third‑party responsibility; coverage may be excluded if another party should pay

When another party is responsible for payment or services are otherwise available (e.g., third-party liability), coverage may be excluded; providers should document efforts to identify third-party responsibility.

• Section 8 excludes services for which another party is responsible; exceptions apply for certain state hospitals, community mental health programs, and VA when care is not service related.
• Document third-party liability and recovery efforts when applicable.

Risk of denial or prior‑auth penalty if required authorization not obtained

Failure to obtain required prior authorization for services listed in SECTION 6 may result in claim denials or application of the prior authorization penalty (50% up to $2,500 per occurrence); providers should obtain authorization in advance to avoid member financial liability.

• Section 6 warns services requiring prior authorization may trigger claim denials if requirements are not met.
• Section 6.1.1/6.1.2 explain the penalty of 50% up to a $2,500 maximum applies when required authorizations are not obtained for out-of-network services (6.1).
• When a service is excluded, charges will be denied even if previously authorized.

Identify prior‑auth services via Member Dashboard to avoid denials

Member Dashboard indicates which services or supplies require prior authorization; providers should verify authorization requirements there to prevent benefit denial.

• Member Dashboard shows whether a service requires prior authorization and provides access to the list of services that must be prior authorized.
• Contact Customer Service or Behavioral Health Customer Service for behavioral health authorization details.

Refer to Section 6 for prior authorization requirements

Consult Section 6 for the full list of services requiring prior authorization; providers should review that section before scheduling or delivering services that may need authorization.

• Section 6 and 6.1.1 enumerate categories of services that may require prior authorization.
• A full list of services that must be prior authorized is available on the Moda Health website/Member Dashboard.

Out‑of‑network non‑emergency admissions subject to $2,000/day limit — risk of denial if exceeded

Out-of-network non-emergency admissions are subject to a per‑day maximum payment (we pay up to $2,000 per day); claims may be denied or limited if this per-day maximum is exceeded.

• Schedule of Benefits notes Moda pays up to $2,000 per day for out-of-network non-emergency admissions.
• Claims may be denied or limited if charges exceed the maximum plan allowance or per-day caps.

Authorization mandatory for nutritional therapy for eating disorders

Nutritional therapy for eating disorders must be authorized; obtain authorization after the initial five visits to ensure continued coverage.

• Schedule of Benefits and Section 3 indicate nutritional therapy for eating disorders must be authorized after the first five visits.
• Providers should request authorization per Section 6 to avoid benefit denial.

Balance billing risk when in‑network facility uses out‑of‑network professionals

Balance billing can occur when an in‑network facility uses out‑of‑network professionals; providers should confirm professional providers' network status to avoid members being billed amounts above the MPA.

• Section 5 warns that out-of-network professionals providing services at an in-network facility may balance bill the member for amounts above the MPA.
• Verify professional providers' in-network participation before services are provided.

Prior authorization required for non‑Moda specialty pharmacy dispensing

Prior authorization is required for non-Moda-designated specialty pharmacies for nonpreferred specialty medications; obtain authorization before dispensing to avoid denials.

• Section 3 and 7.6.5 require prior authorization for non-Moda-designated specialty pharmacies.
• Most specialty medications also require prior authorization and may have supply limits.

Prior authorization penalty: 50% up to $2,500 per occurrence if not authorized

If required prior authorization is not obtained in advance, a penalty of 50% up to a maximum deduction of $2,500 per occurrence may be applied; the penalty does not count toward the deductible or out-of-pocket maximum.

• Section 6.1 states the penalty for not obtaining required authorization when using an out‑of‑network provider is 50% up to $2,500 per occurrence.
• The prior authorization penalty is applied before regular plan benefits and does not apply to emergency admissions.

Excluded services will be denied even if previously authorized

Services that are otherwise excluded from benefits will be denied even if prior authorized; providers must confirm the service is not an exclusion before relying on authorization.

• Section 6 and Section 8 make clear that excluded services are not payable even if prior authorized.
• Providers should review the exclusions list before requesting authorization for services likely to be excluded.

Charges may not be covered if provider fails to obtain required prior authorization

Failure by the doctor to obtain required prior authorization may result in charges not being covered or the member having to pay the full cost or a penalty; confirm authorization status before providing care.

• Section 7.4 warns that charges may not be covered and the member may have to pay full cost or a penalty if the doctor fails to obtain required prior authorization.
• Section 6.1 describes the penalty framework for lacking prior authorization when required.

Out‑of‑network ground ambulance providers may balance bill members

Out-of-network ground ambulance providers may balance bill the member; providers should confirm network participation and seek authorization when applicable.

• Section 7.2.1 notes out-of-network ground ambulance providers may balance bill the member.
• Schedule of Benefits includes out-of-network per-day limits and notes on ambulance coverage.

Non‑covered ABA-related services — risk of denial

Services that do not meet ABA coverage criteria (for example, services provided by family/household members, custodial/respite care, equine or animal therapies, creative arts therapy, neurofeedback, chelation) are not covered and may be denied.

• Section 7.4.2 lists examples of ABA-related services that are not covered, including services by family members and various therapies.
• Section 8 exclusions and DME exclusions provide additional lists of non-covered items.

DME exclusions — comfort/convenience/cosmetic items and certain supplies are denied

DME and appliances primarily for comfort, convenience or cosmetic purposes, dental appliances/braces, incontinence supplies, and specified supporting devices are excluded and may lead to claim denials; prior authorization may still be required for medically necessary DME.

• Section 7.4.9 and Section 7.4.9 Exclusions list appliances not covered even if related to a covered condition.
• Replacement or repair coverage is limited and suppliers may need to provide records to Moda for claim approval.

Respite care and infusion therapy require prior authorization and may be supplier‑restricted

Respite care must be prior authorized and arranged by the attending professional provider; infusion therapy also requires prior authorization and authorization may be limited to specified suppliers or settings.

• Section 7.4.14/Respite Care requires prior authorization and arrangement by the attending provider.
• Section 7.4.18 requires prior authorization for infusion therapy and may limit authorization to preferred suppliers or settings.

Reconstructive surgery requires prior authorization or benefits denied

Reconstructive procedures must be medically necessary and prior authorized; benefits will not be paid for reconstructive surgery that is not prior authorized or not medically necessary.

• Section 7.4.30 states reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid.
• Cosmetic surgery is excluded.

Obtain transplant prior authorization promptly after candidacy is identified

Obtain prior authorization as soon as possible after a patient is identified as a transplant candidate; early authorization helps ensure coverage of recipient and donor-related services.

• Section 7.4.33 advises providers to get prior authorization as soon as possible after transplant candidacy is identified.
• Donor costs and travel/housing have coverage conditions and limits.

Prior authorization may be required for certain maternity diagnostic procedures

Some maternity diagnostic procedures may need prior authorization; providers should consult the Moda Health website or Customer Service for the full list of maternity diagnostics requiring authorization.

• Section 7.5.3 notes diagnostic services related to maternity care may need prior authorization and a full list is on the Moda Health website.
• Contact Customer Service for specifics.

Step therapy ordering: do not submit Step 2 before documented Step 1 trial

If a prescription for a Step 2 medication is submitted before the required Step 1 medication trial, the Step 2 prescription will not be covered; the prescriber must prescribe the Step 1 medication or document an allowable exception.

• Section 7.6.7 states prescriptions submitted out of order (Step 2 before Step 1) will not be covered.
• Providers must document ineffectiveness, intolerance, or lack of equivalent effect to justify an exception.

Specialty pharmacy requirement — prior authorization required for non‑designated pharmacies

Purchasing specialty medications at a non‑Moda‑designated specialty pharmacy without prior authorization will require prior authorization and may be denied; use Moda‑designated specialty pharmacies when required.

• Section 7.6.5 explains most specialty medications must be prior authorized and that buying at non-designated specialty pharmacies requires prior authorization.
• Section 3 notes prior authorization is required for non-Moda-designated specialty pharmacies.

Denial risk for services listed in exclusions (Section 8)

Claims for services listed in the exclusions (Section 8) such as experimental procedures, certain reproductive services, and others will be denied; providers should not expect coverage for excluded services unless a specific exception applies.

• Section 8 lists exclusions including abortion (except limited exceptions), experimental/investigational procedures, and services to treat conditions caused by illegal acts.
• Claims for excluded items will be denied unless an explicit exception elsewhere in the policy applies.

Excluded services (infertility, obesity treatments) will be denied without exception documentation

Claims for services explicitly excluded (for example, infertility treatments, obesity/weight reduction procedures) are subject to denial; obtain prior authorization only when an exception and medical necessity documentation support coverage.

• Section 8 explicitly excludes infertility services and obesity/weight reduction procedures.
• Some exclusions have limited exceptions that require documentation and prior authorization.

Routine foot care excluded unless medically necessary (e.g., diabetes)

Routine foot care services (trimming nails, trimming corns/calluses, removing dead tissue from nails) are excluded unless the member's medical condition (such as diabetes) requires them; document medical necessity to support coverage.

• Section 8 Routine Foot Care excludes these services unless required by a medical condition such as diabetes.
• Provide documentation of the underlying medical condition when requesting coverage.

Telehealth excluded except where specifically allowed (see 7.4.34)

Telehealth is excluded except as specifically described in Section 7.4.34; do not submit claims for telehealth services outside that section expecting coverage.

• Section 8 excludes telehealth except telemedicine specifically described in Section 7.4.34.
• Consult Section 7.4.34 for covered virtual care visit rules and vendors.