Prior authorization required — obtain before service

The policy contains a standalone Prior Authorization section (Services Requiring Prior Authorization and Prior Authorization Limitations). Providers must obtain prior authorization for services specified in that section before providing those services; prior authorization does not guarantee coverage and may require use of a preferred treatment center or supplier.

• See Section 6.1.1 for the full list of services requiring prior authorization.
• Authorization letters will specify any time, quantity, frequency, or provider/center limits.

Verify prior authorization status on Member Dashboard

Before providing a service or supply, check the Member Dashboard (or contact Customer Service) to confirm whether prior authorization is required for that specific item or service.

• Member Dashboard shows services that must be prior authorized.
• Customer Service can provide the up-to-date list and assist with authorization status.

Authorization may be required after initial visits

Some services may require prior authorization after an initial visit threshold; specifically, nutritional therapy for eating disorders must be authorized after the first five visits to continue coverage.

• Initial nutritional therapy visits may be covered, but authorization is required beyond five visits.

Authorize nutritional therapy for eating disorders after 5 visits

Nutritional therapy for eating disorders must be authorized once the patient exceeds five visits; providers should request authorization to continue coverage beyond visit five.

• Document the first five visits and submit a request for authorization to continue care.

Prior authorization for non‑Moda specialty pharmacy or mail‑order

Prior authorization is required for certain pharmacy arrangements: non-Moda-designated specialty pharmacies and some mail-order/anticancer medication scenarios require prior authorization or use of Moda-designated channels.

• Most specialty medications must be obtained from a Moda-designated specialty pharmacy or have prior authorization to use a non-designated pharmacy.
• Mail-order requirements may mandate specific pharmacies that agree to Moda's terms.

Request prior authorization for many inpatient/outpatient services

Providers must request prior authorization in advance for many service types including inpatient/residential programs, outpatient services, rehabilitation therapies, and diagnostic services to avoid penalties and potential denials.

• Emergency admissions are exempt from preauthorization but must be authorized within 48 hours after admission.
• If not authorized in advance (for required services), penalties or denials may apply.

Authorization letters may impose time/quantity/provider limits

Authorizations may include limits—time period, covered items, number/amount/frequency—and may require use of preferred treatment centers or providers; review the authorization letter for any specific limits.

• Care Coordinators/Case Managers can help interpret authorization limits.
• Services provided outside the authorized time frame or limits may not be covered.

Prior authorization required for outpatient, nonemergency inpatient, and specialty programs

Many outpatient services and all nonemergency inpatient and residential care must be prior authorized; most anticancer medications and certain behavioral health programs also require prior authorization—obtain authorization before treatment.

• Behavioral health programs requiring prior authorization include intensive outpatient, ACT, STAR, and TMS.
• Most anticancer medications require prior authorization and often must be obtained via designated specialty pharmacy.

Obtain prior authorization for clinical trials, advanced imaging, gender‑affirming surgery, etc.

Prior authorization is required for participation in clinical trials (for coverage of usual care costs), most advanced imaging services, surgical gender‑affirming procedures, and other specified services—providers must obtain authorization before enrolling or scheduling.

• Approved clinical trials must meet specified funding or FDA investigational criteria.
• Providers must get prior authorization for most MRI/MRA/CT/PET and cardiac imaging studies.

Arrange and prior authorize respite care via attending provider

Respite care for hospice members must be arranged by the attending professional provider and is subject to prior authorization—obtain authorization before scheduling respite services.

• Approval is required for services by non‑professional providers if requested.
• Care arranged to allow a caregiver to return to work does not qualify.

Prior authorization required for infusion therapy and related services

Infusion therapy services and associated supplies require prior authorization; the provider must obtain authorization for the therapy and related pharmacy/DME/nursing services before delivering infusion care.

• Some infusion medications may be limited to certain providers or settings and/or covered under the pharmacy specialty benefit.
• When authorization is limited to a specific supplier or setting, services from other sources may not be covered.

Prior authorize medications/treatments in centers or from specified suppliers

Medications and treatments administered in treatment/infusion centers or by specific suppliers require prior authorization; some medications also require use of preferred suppliers—confirm authorization and supplier requirements before treatment.

• When limited to preferred suppliers, medications from other suppliers may not be covered.
• Some infusion medications are covered under the pharmacy specialty benefit and require designated sourcing.

Obtain prior authorization for reconstructive surgery and some maternity diagnostics

Reconstructive procedures and certain diagnostic maternity services require prior authorization; providers must obtain prior authorization before performing these services to ensure coverage.

• All reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid.
• Some maternity diagnostic procedures may require separate prior authorization.

Prior authorization required for certain medications and quantities

Certain medications and specific quantities require prior authorization; most specialty medications must be prior authorized and prior authorization may be time‑limited (for example until a generic becomes available).

• Brand medications may be authorized only for a set period; coverage can change when a generic becomes available.
• Providers can request a formulary exception with supporting clinical documentation.

Prior authorization note — cosmetic procedures generally excluded

Cosmetic procedures are listed as excluded unless a specific medical necessity exception applies; prior authorization is not applicable to excluded cosmetic services except where reconstructive exceptions are specified.

• Reconstructive or gender‑affirming surgery may be covered if medically necessary and prior authorized per relevant sections.

Self‑administered medications obtained outside pharmacy are excluded

Self‑administered medications obtained directly from a physician's office, facility or clinic instead of through the pharmacy benefit are excluded; use the pharmacy benefit and prior authorization processes where applicable.

• Self‑administered injectables obtained in office/clinic are not covered under the medical/infusion benefit; check pharmacy routes.

Telemedicine exceptions and possible authorization

Telemedicine is excluded except as specifically described (see section 7.4.34); where telemedicine services are allowed, prior authorization may be required per the referenced sections.

• Virtual Care Visits via the preferred vendor (CirrusMD) are described in Section 7.4.34 and may be covered.
• Confirm coverage and any authorization requirements on the Member Dashboard.

Use pre‑service appeals for prior authorization denials

Pre‑service appeals apply to services that must be prior authorized but have not yet been provided; submit appeals in writing and an independent reviewer will investigate the pre‑service appeal.

• Moda will send a pre‑service appeal decision within 15 days; follow instructions in the adverse determination letter to appeal.
• Contact Customer Service for help preparing a pre‑service appeal.

Follow step therapy: try Step 1 before Step 2 unless exception documented

Step therapy rules apply to certain medications: providers must prescribe and document trial of required Step 1 medications before Step 2 medications will be covered unless an exception applies.

• Exceptions are granted if Step 1 is ineffective, harmful, or not equivalent to the requested Step 2 medication.
• Exceptions and formulary issues can be requested via the Member Dashboard or Pharmacy Customer Service.

Adhere to provider/setting limitations for some infusion/dialysis meds

Some infusion and dialysis medications may be limited to certain providers or covered under the specialty pharmacy benefit; follow site‑of‑care and supplier requirements when ordering these medications.

• When authorization is limited to a particular supplier or setting, services from other sources may not be covered.
• Confirm whether a drug is covered under pharmacy specialty benefit or medical/infusion benefit.

Confirm Moda‑designated pharmacy and tiering for medications

Moda-designated pharmacy and specialty supply rules affect coverage and prior authorization; use the Member Dashboard or Pharmacy Customer Service to confirm tiering and prior authorization requirements for a medication.

• Certain mail‑order and specialty pharmacy arrangements require use of designated pharmacies or prior authorization.

Use preferred centers/providers when required by authorization

Use preferred treatment centers or providers as required to obtain higher benefit levels or coverage; check the Member Dashboard and the authorization letter for any specified preferred center requirements.

• Authorization letters will state if treatment must be obtained from a preferred center to be covered at a higher benefit level.
• Failure to use a preferred center when required may reduce benefits or result in noncoverage.

Obtain specialty pharmacy authorization or use designated supplier for anticancer meds

Designated specialty pharmacy or enrollment in utilization programs may be required for specialty anticancer medications; obtain prior authorization if using a non‑designated specialty pharmacy.

• Some anticancer medications require enrollment in specific programs to ensure correct use and cost management.
• Contact Pharmacy Customer Service or check the Member Dashboard for specialty pharmacy requirements.

Source insulin/diabetes supplies via pharmacy with prescription and preferred manufacturer

Insulin and diabetic supplies are covered under the pharmacy benefit when purchased from a pharmacy with a valid prescription and using preferred manufacturers; insulin pumps may be DME if not obtained from a pharmacy.

• Prescribe and document use of preferred manufacturers to ensure pharmacy benefit coverage.
• If supplies are obtained via DME route, prior authorization and supplier documentation may be required.

Order infusion/specialty meds from preferred suppliers when specified

Some infusion and specialty medications must come from preferred suppliers or be covered under the pharmacy specialty benefit; when limited to a supplier or setting, other sources may not be covered.

• When prior authorization designates a supplier, order through that supplier to avoid denials.
• Check authorization letter for supplier restrictions.

Follow formulary/tiering rules and submit formulary exception documentation when needed

Formulary and tiering rules, including brand substitution and tier designations, affect coverage and member cost‑sharing; providers should consider formulary options and document medical necessity for exceptions.

• Formulary exception requests require provider contact information and documentation showing trials/intolerance/inefficacy of formulary options.
• Decisions on exceptions are made within 72 hours (24 hours for urgent requests).

Ensure step therapy sequencing and document exceptions

Step therapy requires trying Step 1 medications before Step 2 will be covered; if the provider prescribes Step 2 first, the prescription will not be covered unless an exception (ineffective, harmful, or non‑equivalent) is documented.

• If Step therapy is bypassed, the provider must document reasons for exception and request coverage via Pharmacy Customer Service or Member Dashboard.

Obesity/weight‑reduction services excluded except ACA‑required coverage

Weight management programs, bariatric procedures, and related medications/formulas are excluded except where coverage is required by the ACA; do not authorize or bill these services unless an ACA‑required exception applies.

• Services to treat medical conditions caused by obesity may be covered; document the condition and apply applicable coverage rules.

Provide/justify least costly safe alternative when requesting coverage

Services must be the least costly safe alternative; lack of a less costly alternative may affect coverage determinations and utilization review decisions.

• Document why a less costly alternative is not suitable if requesting a higher‑cost option.

Utilization review may deem services not medically necessary or investigational

Utilization review determinations may result in findings that services are not medically necessary, investigational, or require medical judgment, which can affect prior authorization, step therapy, and coverage decisions.

• If services are determined not medically necessary or investigational, claims will be denied; providers should supply evidence‑based documentation to support medical necessity.

Check Member Dashboard and contact Customer Service for authorizations

Use the Member Dashboard or the contact numbers listed in section 2.1 to find prior authorization requirements, submit requests, and get policy information; Member Dashboard also identifies services requiring prior authorization.

• Member Dashboard is available 24/7 and lists authorization requirements and formulary/tier information.
• Contact Customer Service or Behavioral Health Customer Service for specialty assistance.

Verify member ID card and network before service

Verify the member's ID card and network at the time of service so providers can confirm coverage and appropriate billing; failure to confirm may lead to balance billing or reduced benefits.

• Ask members to present their ID card at each visit and confirm network/care pathways.
• If out‑of‑network providers are used, members may be balance billed for amounts above the MPA.

Out‑of‑network pharmacy — member pays amounts above MPA

When members use an out‑of‑network pharmacy, they are responsible for any amounts charged above the maximum plan allowance (MPA); inform members and document pharmacy sourcing decisions.

• Providers and members should use participating pharmacies or Moda‑designated mail order to avoid excess charges.
• Advise members that out‑of‑network pharmacy charges above the MPA may not be covered.

Provide QMCSO/full‑time student documentation for out‑of‑area child coverage

For children living outside the service area under QMCSO or as full‑time students, providers or families must submit documentation (address, enrollment, or QMCSO) to Customer Service to assign out‑of‑area network coverage.

• Coverage assignment takes effect the first day of the month after documentation is received.
• Contact Customer Service to submit required documents.

Initiate prior authorization requests via Moda Health/Member Dashboard

Providers should contact Moda Health for prior authorization before performing services that require authorization; a full list of services and supplies that require prior authorization is available on the Moda Health website and Member Dashboard.

• Behavioral health prior authorizations are handled via Behavioral Health Customer Service.
• Authorization requirements are updated periodically on the website/Member Dashboard.

Document examination for urgent care and obtain authorizations for outpatient/nonemergency inpatient care

For urgent care visits, the member must be actually examined by a professional provider; many outpatient services and all nonemergency inpatient/residential care must be prior authorized—ensure exam documentation and authorization as required.

• If an urgent care facility does not bill as urgent care, the visit will be processed under office visit benefits.
• Document the professional provider's examination for urgent care claims.

Provide DME orders/records when requested to support claims

For DME claims, if requested you must authorize the DME supplier to provide equipment order details and other records Moda requests to approve claim payment.

• Provide itemized DME orders, supplier invoices, and proof of medical necessity when requested.
• Replacement/repair coverage requires confirmation the item was not abused and is within warranty terms.

Submit written hospice treatment plan and periodic reviews

A written hospice treatment plan is required and must be established and periodically reviewed by the treating provider certifying terminal illness; include the plan in authorization and claims documentation.

• The plan must describe services and supplies to be provided and certify terminal illness.
• Respite care within hospice requires prior authorization arranged by the attending provider.

Document medical necessity and physician supervision for prior authorization

Services must be medically necessary and supervised by licensed physicians; prior authorization is required for certain services (infusion therapy, some medications, surgeries in alternate settings) — include documentation of medical necessity and supervising provider when requesting authorization.

• Include supervising physician details and clinical rationale in authorization requests.
• Care Coordinators can assist with accessing authorized treatment pathways.

Reference Moda Health website/Customer Service for full prior authorization list

A full list of services that must be prior authorized is available on the Moda Health website or via Customer Service; check these resources for diagnostic maternity and other specific prior authorization requirements.

• Some diagnostic maternity procedures may require separate prior authorization; confirm before scheduling.
• Use Member Dashboard to find the most current list of required prior authorizations.

Submit formulary exception requests with required clinical details

Formulary exception requests must include prescriber contact information and supporting provider documentation showing trials of formulary medications, intolerance or inefficacy, and why the requested medication is not experimental.

• Decisions for exception requests are provided within 72 hours (24 hours if urgent).
• Include dose/duration details of prior formulary medication trials in documentation.

Document medical necessity for reconstructive/gender‑affirming procedures

When billing procedures that may be reconstructive or gender‑affirming, document medical necessity and reference applicable authorization or coverage sections to support coverage and avoid denials.

• Reconstructive surgery must be prior authorized and shown to be medically necessary.
• Gender‑affirming surgical procedures require prior authorization and supporting treatment plans.

Document qualifying medical condition for routine foot care

For routine foot care to be covered, document a qualifying medical condition (e.g., diabetes) that justifies the foot care services; otherwise routine foot care services are excluded.

• Include relevant diagnoses (for example diabetes) and clinical notes supporting medical necessity.

Provide exception documentation to justify excluded/limited services

Provide clinical documentation to demonstrate medical necessity for any exception (for example orthognathic surgery only when repairing accidental injury or for cancer treatment); include relevant operative, diagnostic, or injury records.

• For orthognathic exceptions, submit evidence of accidental injury repair or cancer treatment as applicable.
• Explain why standard or less expensive alternatives are not suitable.

Document hearing aid order date to support post‑coverage dispensing

For hearing aids ordered before coverage ends, document the order date so dispensing within 90 days after policy termination can be confirmed for potential coverage.

• Maintain and submit the original order date and dispensing records when filing claims after coverage ends.

Document prescription‑only vitamins/minerals and medical necessity

If vitamins or minerals are claimed under the medical benefit, include documentation that the product requires a prescription and is medically necessary to treat a specific condition; over‑the‑counter formulations are not covered.

• Show that an equal or greater strength dosage form is not available OTC without a prescription.
• Specify route (oral, injectable, transdermal) and clinical indication.

Include required claim documentation and supporting details

Submit itemized claims including patient/subscriber name and ID, date of service, diagnosis with ICD codes, itemized services with CPT/HCPCS codes, provider tax ID, and proof of payment; include additional required details for accidental injury, ambulance, vision, and out‑of‑country care as listed.

• Include accident details, pickup/drop‑off locations for ambulance, and translated medical records and proof of payment for out‑of‑country care.
• Provide provider tax ID and proof of payment (credit card statement or cancelled check) where required.

Submit notice and proof of loss on time for claim filing

Provide written notice of claim within 20 days of loss; if claim forms are not received within 15 days, submit written proof of loss without waiting for forms to avoid delays in claims processing.

• Download claim forms from the Moda Health website if needed.
• Timely notice preserves rights to coverage and reimbursement.

Denial risk if required prior authorization is not obtained

Services listed in the Services Requiring Prior Authorization section may be denied if prior authorization is not obtained; providers must secure authorization to reduce denial risk.

• If services that require authorization are performed without it, claims may be denied or a penalty applied.
• Out‑of‑network prior authorization failures may trigger a penalty of 50% up to $2,500 per occurrence.

Member Dashboard identifies prior authorization requirements — check before treatment

Use the Member Dashboard to identify services or supplies that require prior authorization; failure to obtain required authorization identified there may lead to denial or member financial responsibility.

• Member Dashboard lists authorization requirements and formulary/tier information.
• Customer Service can verify prior authorization obligations when needed.

Authorization required after 5 nutritional therapy visits — denial risk if not obtained

Nutritional therapy for eating disorders must be authorized after the first five visits; failure to obtain authorization for additional visits may result in denial of coverage for those visits.

• Document initial five visits and request authorization before the sixth visit to maintain coverage.

Balance billing risk — charges above MPA may be member responsibility

Providers may balance bill members for amounts charged above the Maximum Plan Allowance (MPA) when services are provided by out‑of‑network providers or when provider charges exceed the MPA; inform members and document network status.

• Encourage use of in‑network providers to avoid member balance billing.
• When at an in‑network facility, request in‑network providers for ancillary services to reduce balance billing risk.

Prior authorization penalty and emergency authorization timing

If services using an out‑of‑network provider are not authorized in advance, a prior authorization penalty of 50% (up to $2,500 per occurrence) will be applied before regular plan benefits begin; emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).

• The prior authorization penalty does not count toward the plan deductible or out‑of‑pocket maximum.
• Emergency admissions are exempt from the advance authorization penalty but require post‑admission authorization within 48 hours.

Failure to obtain prior authorization may result in member/provider liability

If the required prior authorization is not obtained by the provider, charges may not be covered and the member may be responsible for full costs or penalties—ensure authorizations are in place prior to care when required.

• Denials due to missing prior authorization are assessed via utilization review.
• Providers should document attempts to obtain authorization for emergency or unforeseen situations.

Advanced imaging prior authorization required — risk of denial if missing

Failure to obtain prior authorization for most advanced imaging services (MRI, MRA, CT, PET, nuclear medicine and cardiac imaging) may trigger denial; providers must seek authorization before ordering these studies.

• A full list of diagnostic procedures requiring prior authorization is available on the Moda Health website.
• Include clinical indications and prior conservative management documentation when requesting imaging authorization.

Prior authorization required for clinical trial participation — denial risk if not obtained

Participation in an approved clinical trial requires prior authorization; lack of prior authorization for clinical trial participation may lead to denial of coverage for usual care costs.

• Approved trials must meet funding or FDA investigational criteria listed in policy.
• Obtain authorization prior to enrolling the member to secure coverage for usual care costs.

Authorize gender‑affirming surgical procedures or risk denial

Surgical gender‑affirming procedures require prior authorization; absence of prior authorization may result in claim denial—ensure surgical plans and medical necessity documentation are submitted and authorized beforehand.

• Gender‑affirming treatment plans must meet medical necessity criteria and surgeries must be performed by qualified professional providers.
• Include mental health and hormone therapy documentation as part of the treatment plan where applicable.

Respite care requires prior authorization — denial risk if not obtained

Respite care must be prior authorized and arranged by the attending professional provider; lack of prior authorization for respite care may result in denial of coverage.

• Non‑professional provider services for respite require prior approval.
• Respite care does not include care to permit a caregiver to return to work.

Infusion therapy prior authorization required — denial risk if missing

Failure to obtain prior authorization for infusion therapy may lead to denial of infusion therapy services; providers must secure authorization for the therapy and related supplies/services before treatment.

• Authorization may require use of preferred medication suppliers or home infusion providers.
• Document clinical necessity and monitoring plans when requesting infusion authorization.

Prior authorize treatment‑center medications or risk denial

Medications administered in treatment/infusion centers or that require use of a preferred treatment center must be prior authorized; services not prior authorized or administered outside designated settings may be denied.

• When authorization designates a treatment center or supplier, obtain services there to ensure coverage.
• Check whether the medication is billed under pharmacy specialty or medical/infusion benefit.

Reconstructive surgery must be prior authorized and medically necessary

Reconstructive procedures that are not medically necessary or not prior authorized will not be paid; obtain prior authorization and submit medical necessity documentation before surgery.

• Reconstructive surgery that is partially cosmetic may be covered if medical necessity is established and authorized.
• Surgeries related to mastectomy reconstruction have specific coverage rules—authorize in advance.

Transplant donor cost coverage limited by enrollment status

If a transplant donor or recipient enrollment condition is not met (donor or recipient not enrolled), donor‑related costs or complications may not be paid; providers must verify enrollment and obtain required authorizations.

• Donor costs are covered when the recipient or self‑donor is enrolled; if donor is not enrolled and recipient is not enrolled, donor costs are excluded.
• Verify enrollment status before scheduling transplant‑related donor procedures.

Do not prescribe Step 2 before Step 1 — step therapy ordering requirement

When prescribing medications subject to step therapy, do not submit Step 2 prescriptions before the member has tried Step 1; if Step 2 is submitted out of order, it will not be covered and the provider must prescribe Step 1 first unless an exception is documented.

• Document prior trials and clinical rationale when requesting an exception to step therapy.
• Pharmacy Customer Service can assist with step therapy questions and exception requests.

Prior authorization and designated specialty pharmacy required for many specialty meds

Failure to obtain prior authorization for certain medications (including most specialty medications) or purchasing specialty medications at a non‑designated specialty pharmacy without authorization may result in noncoverage.

• Most specialty medications require prior authorization and must be obtained from Moda‑designated specialty pharmacies unless prior authorization for a non‑designated pharmacy is obtained.
• Some specialty prescriptions may be limited to less than 30 days or require enrollment in a utilization program.

Excluded service categories — risk of denial

Claims for services listed as cosmetic, experimental/investigational, infertility treatment, or services related to never events are excluded and will be denied per the policy; do not submit authorization for excluded services unless a specific exception applies and is documented.

• Experimental/investigational procedures and never events are explicitly excluded.
• Infertility services are excluded in full.

Excluded items/services may be denied — verify exceptions before billing

Claims for items and services explicitly listed as exclusions (naturopathic supplies; never events; non‑therapeutic counseling; nuclear radiation conditions; obesity treatments; routine foot care except when medically required; self‑administered clinic/office meds; etc.) are subject to denial—do not bill these under the medical benefit unless a specific exception and authorization exist.

• Review Section 8 and related sections for detailed exclusion listings before authorizing or billing.
• When a service appears excluded, document any legal/ACA exceptions that may override the exclusion.

Third‑party responsibility may lead to denial — verify primary payer

Claims may be denied if another third party is responsible for payment (third‑party liability) or if charges were reduced or would be covered by another program; confirm third‑party responsibility before submitting claims to Moda.

• Coordinate with other payers and document any recoveries or third‑party obligations.
• This exclusion does not apply where state or federal rules require Moda to pay first.

Medical necessity denials — document evidence‑based need

Services that do not meet the plan's medical necessity criteria (inappropriate, not standard treatment, primarily for convenience, or not the least costly safe alternative) will be denied; provide evidence‑based documentation to support medical necessity.

• Medical necessity criteria a–e must be addressed in clinical documentation for authorization or appeals.
• If denied for medical necessity, an internal appeal or external review process may be pursued per appeal timelines.

Reasons for utilization review denials — prepare supporting documentation

Denials can be issued when care is not medically necessary or appropriate, is investigational or experimental, or when the decision involves medical judgment; providers should supply clinical evidence and rationale to support utilization review and appeals.

• Appeals must be submitted in writing and will be reviewed by someone not involved in the original decision.
• Pre‑service appeals decisions are provided within 15 days; post‑service appeals within 30 days.