Prior Authorization requirements

Prior authorization requirements and services requiring prior authorization are covered in SECTION 6 (Prior Authorization). Providers must follow the procedures in that section to request authorization before services that require it.

• See Section 6.1 for details on services requiring prior authorization and Section 6.1.2 for authorization limitations.

Check Member Dashboard for prior authorization

Check the Member Dashboard before providing services to confirm whether the service or supply requires prior authorization and to view the current prior authorization list.

• Member Dashboard shows whether a service/supply must be prior authorized.
• Contact Customer Service or Behavioral Health Customer Service for authorization status if needed.

Prior authorization may be required

Prior authorization may be required for some services; providers should contact Moda Health for authorization before providing services that may require it.

• Prior authorization applies to many outpatient services and all nonemergency inpatient and residential care.
• Authorizations may limit time, amount, frequency, or require use of preferred treatment centers.

Prior authorization for specialty pharmacy and certain nutrition therapy

Prior authorization is required for specialty medications obtained from non‑Moda‑designated specialty pharmacies and for nutritional therapy for eating disorders after the first five visits.

• Most specialty medications must be prior authorized; buying specialty meds at non‑Moda designated specialty pharmacies requires prior authorization.
• Nutritional therapy for eating disorders must be authorized after the first 5 visits (see Schedule of Benefits/Section 7.4.23).

Services requiring prior authorization

Many inpatient, outpatient, rehabilitation (physical/occupational/speech) and diagnostic services (including advanced imaging) require prior authorization; providers must obtain authorization before these services.

• Advanced imaging (MRI/MRA, CT, PET, nuclear medicine, cardiac imaging) requires prior authorization (provider must obtain prior auth for most advanced imaging).
• Rehabilitation and diagnostic services may be time- or frequency-limited by authorization.

Out-of-network prior authorization requirement

When using an out-of-network provider, the provider must obtain prior authorization; failure to obtain authorization may trigger a 50% penalty up to $2,500 per occurrence before regular plan benefits begin.

• The prior authorization penalty does not count toward the deductible or out-of-pocket maximum.
• Prior authorization is not required for emergency admissions, and the penalty does not apply to emergency admissions.

Prior authorization requirements

Many outpatient services and all nonemergency inpatient and residential care must be prior authorized; providers should contact Moda Health before scheduling nonemergency admissions or services.

• If required prior authorization is not obtained, charges may not be covered or a penalty may apply.
• Emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).

Prior authorization requirements (clinical trials, imaging, DME, gender-affirming surgery)

Prior authorization is required for participation in approved clinical trials, most advanced imaging, some DME, and surgical gender‑affirming procedures; providers must request authorization prior to enrollment or performing these services.

• Clinical trial participation must be prior authorized; usual care costs covered only for approved trials.
• Prior authorization required for surgical gender-affirming procedures and for some DME.

Prior authorization required (respite, infusion, meds, procedures)

Prior authorization is required for respite care, infusion therapy, and some facility-based medications/treatment programs; providers must obtain authorization and may be required to use preferred suppliers or settings.

• Infusion therapy requires prior authorization and may be limited to preferred medication suppliers, home infusion providers or certain settings.
• Respite care must be arranged by the attending professional provider and be prior authorized.

Prior authorization required for specified services (reconstructive, maternity diagnostics, vision)

Certain reconstructive surgeries, specified maternity diagnostic procedures, and some vision services require prior authorization; providers should check Moda's prior authorization list or contact Customer Service before proceeding.

• Reconstructive surgery must be medically necessary and prior authorized or benefits will not be paid.
• Some vision services (and VSP in-network authorizations) require identification as a VSP member and prior authorization where applicable.

Transplant prior authorization

Providers should obtain prior authorization for transplant candidates as soon as possible after identifying a potential transplant candidate; authorization is expected early in the transplant evaluation process.

• Transplant prior authorization should be obtained promptly; facility choice (Center of Excellence vs. other) affects benefit accumulation and limits.
• Donor cost coverage and travel/housing limits are addressed when authorization is obtained.

Specialty medication prior authorization

Most specialty medications require prior authorization; if specialty medications are purchased at non‑Moda‑designated specialty pharmacies, prior authorization is required and supply limits may apply.

• Some specialty medications may be limited to less than 30 days or to specific supply limits; prior authorization letter will specify limits.
• Specialty anticancer medications must be obtained from Moda's designated specialty pharmacy or get prior authorization to use a non‑designated pharmacy.

Prior Authorization and Exclusions

Services that are cosmetic, experimental or investigational are excluded from coverage; prior authorization will not make excluded services payable unless medical necessity documentation shows an applicable exception.

• Experimental/investigational items and items only required to provide/monitor the investigational item are not covered even with prior authorization.
• Orthognathic and other excluded procedures remain denied unless an explicit exception applies (see exclusions).

Prior authorization for orthognathic surgery when exception applies

Orthognathic surgery and associated services are excluded except when medically necessary to repair an accidental injury or to treat cancer; in those cases, prior authorization should document the medical necessity exception.

• If orthognathic surgery falls under an exception (accidental injury or cancer treatment), providers must reflect that medical necessity in the prior authorization request.
• Otherwise charges for orthognathic surgery will be denied as excluded.

Exceptions and referenced prior-auth sections (telemedicine, vision)

Telemedicine is excluded except as specifically described in section 7.4.34; vision services are generally excluded except where specifically covered (pediatric/adult/diabetes vision sections); follow the referenced prior-authorization sections where exceptions exist.

• Providers must use section 7.4.34 for allowed telemedicine services and VSP processes for in-network vision authorizations.
• When services are outside the covered exceptions, prior authorization will not make them payable.

Prior authorization linkage to pre-service appeals

Pre-service appeals relate to services that must be prior authorized; a decision on a pre-service appeal will be sent within 15 days from receipt.

• Providers or members may file a pre-service appeal when prior authorization is required and denied.
• Expedited internal appeals have faster timelines (see Appeals section for details).

Expedited external review timing

Members may file an expedited external review (urgent care request) concurrently with an internal urgent appeal; the plan will determine eligibility for expedited external review within two full business days and notify within one business day of the eligibility decision.

• If eligible, the IRO must decide the expedited external review within 72 hours; written confirmation follows within 48 hours.
• Providers may assist members with necessary forms and authorization releases for external review.

Pharmacy step therapy

Step therapy for medications is governed under the pharmacy benefit (SECTION 7.6); when a medication is part of step therapy, the member must try required Step 1 medications before Step 2 will be covered unless an exception applies.

• If a Step 2 medication is submitted before required Step 1 trials, the prescription will not be covered and the provider must prescribe the Step 1 medication.
• Exceptions allowed if Step 1 is ineffective, harmful, or not equivalent.

Prescription Price check tool

Providers and members can use the Prescription Price check tool on the Member Dashboard to review medication cost estimates, benefit tiers, and any step therapy requirements before prescribing or filling medications.

• Tool shows formulary status and whether a medication may require prior authorization or step therapy.
• Contact Pharmacy Customer Service for assistance coordinating refills or formulary questions.

Infusion medication coverage / setting limits

Some infusion medications are covered only in certain settings or from preferred suppliers; providers must obtain prior authorization and may be required to use a preferred medication supplier, home infusion provider or treatment center.

• Infusion therapy requires prior authorization and may limit the supplier, setting, number, amount or frequency of services.
• Certain infusion medications are covered under the pharmacy specialty benefit and may require use of a designated supplier.

Specialty pharmacy designation

Prior authorization is required for non‑Moda‑designated specialty pharmacies; specialty medications must generally be obtained from Moda‑designated specialty pharmacies or receive prior authorization to use a non‑designated vendor.

• Most specialty medications must be prior authorized and may have supply limits or enrollment program requirements.
• Non‑Moda specialty pharmacy purchases require prior authorization.

Authorization limits and treatment center requirements

Authorizations may limit the number, amount or frequency of services and may require use of a preferred treatment center or supplier; providers should document medical necessity and follow evidence‑based criteria during authorization requests.

• The authorization letter will describe any specific limits or requirements that apply to the authorized services.
• Care coordinators or case managers can assist providers and members in accessing authorized treatment.

Anticancer medication specialty pharmacy

Some anticancer medications have specific benefit limitations and enrollment programs; specialty anticancer medications must be obtained from the designated specialty pharmacy or prior authorization obtained to use a non-designated pharmacy.

• Most anticancer medications require prior authorization and may require enrollment in programs to ensure proper use.
• Check Member Dashboard or contact Customer Service for anticancer specialty pharmacy requirements.

Diabetes benefit sourcing

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 may be covered under DME if not obtained from a pharmacy.

• Prescribers should ensure prescriptions use preferred manufacturers to meet pharmacy benefit rules.
• Insulin pumps obtained through DME may require prior authorization per Section 7.4.9.

Preferred supplier requirements

Members may be required to use a preferred medication supplier, home infusion provider, or preferred treatment center for coverage of certain infusion medications and services; providers should verify preferred suppliers during authorization.

• If authorization is limited to a certain supplier or setting, medications or services obtained elsewhere may not be covered.
• Providers may need to coordinate with Moda to identify preferred suppliers for the member.

Outpatient vs inpatient payment responsibilities for transplant meds

For transplant-related medications: inpatient immunosuppressives are covered as medical supplies during the hospital stay; outpatient oral and self-injectable immunosuppressives are paid under the pharmacy benefit—providers should coordinate benefit routing and prior authorization as appropriate.

• Authorize transplant services early and document medical necessity for coverage.
• Ensure outpatient immunosuppressives are prescribed and filled under the pharmacy benefit to receive appropriate reimbursement.

Step therapy operational note for medications

Operational step therapy rules: when a step therapy medication is part of the pharmacy program, providers must prescribe required Step 1 agents first or document an allowable exception (ineffective, harmful, or not equivalent) to obtain coverage for Step 2 medications.

• If Step 2 is submitted out of order, the prescription will not be covered and the provider must prescribe the Step 1 medication.
• Formulary exception requests may be submitted with supporting provider documentation; decisions are made within 72 hours (24 hours if urgent).

Infertility Services exclusion

Infertility services, including diagnosis and treatment and surgery to reverse elective sterilization, are excluded from coverage; do not submit prior authorization requests for excluded infertility services.

• Since infertility services are excluded, step therapy and pharmacy prior authorization processes do not apply to these services.
• Providers should inform members that infertility services are not covered under this policy.

PROVIDER ACTIONS (summary)

Providers must follow the prior authorization rules in Section 6 and use the Member Dashboard or Customer Service contacts to verify authorization requirements before delivering services.

• Emergency admissions require notification/authorization within 48 hours after admission (or as soon as reasonably possible).
• A full list of services requiring prior authorization is maintained on the Moda Health website.

Primary-plan compliance effect on COB

If the primary plan denied an expense because the member failed to follow that plan's rules (for example, failing to obtain prior authorization), this plan will not cover that expense when acting as the secondary plan.

• Providers must submit the primary plan's EOB when this plan is secondary to support coordination of benefits.
• Documentation of primary-plan denials is required for secondary payment consideration.

Member/provider documentation & contact

Members and providers should use the Member Dashboard or the phone numbers in section 2.1 for policy information; providers must document medical necessity and include required supporting records when requesting authorizations or submitting claims.

• Include clinical documentation to support medical necessity in prior authorization requests.
• Contact Customer Service for authorization status or appeals assistance.

Member ID card

Members must present their Moda Health ID card at each visit so providers can verify membership and network; if lost, replacement ID cards are available through the Member Dashboard or Customer Service.

• Providers should verify the member's network and ID prior to scheduling services that may require in-network provider status for coverage.

Member ID card at point of service

At the point of service, members should present their Moda Health ID card so providers can confirm enrollment and network; providers should confirm eligibility prior to providing scheduled services.

• If a provider is out-of-network, verify whether prior authorization is required to avoid penalties or member balance billing.

Documentation for out-of-area child assignment

When adding a child under a Qualified Medical Support Order (QMCSO) or when an enrolled child moves outside the service area, contact Customer Service and provide documentation (address or school enrollment) to assign the out-of-area network.

• The enrolled child will be assigned to the out-of-area network on the first day of the month after documentation is received and the address updated.

Prior authorization timing and process

Providers should contact Moda Health for prior authorization before services that require it; emergency hospital admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).

• Authorization letters will state any limits (time, amount, frequency) and provider obligations.
• Failure to obtain required prior authorization may result in denial or penalties.

Authorization list and contacts

A full list of services and supplies that must be prior authorized is maintained on the Moda Health website; providers may contact Customer Service or Behavioral Health Customer Service for authorization status or to request an authorization.

• Authorization details and any limits are described in the authorization letter sent to the provider and member.

Notification and prior authorization

Notify the PCP as soon as possible after emergency care; many outpatient services and all nonemergency inpatient/residential care must be prior authorized per Section 6.1.

• Emergency medical screening and stabilization do not require prior authorization.
• Nonemergency admissions and most outpatient services require prior authorization before care.

DME documentation

Provider may need to prior authorize some DME and must provide information about the equipment order and records if requested to approve a claim payment; replacements/repairs are covered only under conditions specified in Section 7.4.9.

• All DME, supplies and appliances must be medically necessary.
• If requested, providers must authorize suppliers to release equipment order details and records to Moda.

Home health and hospice documentation

Home healthcare must be ordered by the treating practitioner or specialist and be medically necessary; hospice treatment plans must be written, periodically reviewed, and prior authorized when required.

• Home health visits must be intermittent and provided by qualified professionals; home health aides are not covered under general home healthcare.
• Hospice requires Medicare approval/accreditation and a written hospice treatment plan certifying terminal illness.

Prior authorization and documentation (respite, infusion, meds)

Prior authorization is required for respite care, infusion therapy, and some facility-based medication/treatment programs; documentation should include the attending provider's arrangement and medical necessity.

• Respite care must be arranged by the attending professional provider and prior authorized.
• Infusion therapy prior authorization should specify supplier, setting, and any limitations.

Transplant provider documentation

Providers should document transplant necessity and follow standard medical practice; prior authorization is expected for transplant candidates as soon as possible after identifying potential candidacy.

• Authorization should include clinical documentation and anticipated facility for the transplant.
• Donor cost coverage and travel/housing limits are addressed when authorization is obtained.

Breast pump medical necessity documentation

Medical necessity documentation is required for hospital-grade breast pumps and for purchasing or renting breast pumps and supplies under breastfeeding support; charges for extra ice packs or coolers are not covered.

• Hospital-grade pumps are covered when medically necessary and documentation must support that need.
• Retail purchases are subject to the maximum plan allowance (MPA) and may require proof of medical necessity.

Formulary exception request details

Formulary exception requests must include prescribing provider contact information and documentation showing trials, intolerance, harm, or that formulary options are expected to be harmful or not provide equivalent results; decisions are made within 72 hours or 24 hours if urgent.

• We will contact the prescribing provider to understand treatment and make a decision within the stated timelines.
• This process is used when a non‑formulary medication is medically necessary; it is not used for generic substitution or plan limitations.

Custodial Care documentation requirement

Documentation showing medical necessity is required for services that might otherwise be considered custodial; routine custodial care is excluded and will be denied without appropriate documentation.

• Custodial care (assistance with activities of daily living) is excluded unless documentation shows medical necessity.
• Providers should include clinical justification when requesting coverage for services that could be custodial.

Routine foot care documentation exception (e.g., diabetes)

Routine foot care services are excluded unless medically required for an underlying condition (e.g., diabetes); providers must document medical necessity to support coverage as an exception.

• Routine trimming of nails, callus care, and similar routine foot care are excluded unless related to a covered medical condition.
• For diabetic patients, document the condition that makes routine foot care medically necessary.

Documentation to support medical necessity

Providers should ensure documentation supports medical necessity for exams, testing, or treatments; services done for administrative, employment, licensing, insurance, or legal purposes are excluded.

• Include clinical rationale, diagnosis codes, and relevant records when submitting authorizations or claims.
• Administrative or qualification examinations should not be billed as medically necessary services.

Bill submission requirements when billing directly

When billing directly to Moda (member reimburses provider then submits claim), include patient and subscriber name and ID, date of service, diagnosis (including ICD codes), itemized services and charges (including CPT/HCPCS), provider tax ID, and proof of payment.

• Additional documentation may be required for accidental injury, ambulance service, vision services reimbursement, and out-of-country care.
• Incomplete claims may be denied but the member/provider will be notified and given time to supply additional information.

External review documentation

External review requests must include a completed authorization form allowing release of medical records the independent review organization may require; this is required before the department will act on an external review request.

• Include the 'Appointment of an Authorized Representative' form if someone else will represent the member.
• Standard external review timelines and eligibility steps are detailed in the External Review section.

COB documentation when plan is secondary

If this plan is secondary, providers must submit a copy of the primary plan's Explanation of Benefits (EOB) to coordinate benefits; if the primary plan denied an expense because the member failed to follow that plan's rules, this plan will not cover the expense either.

• The primary EOB is required to determine secondary payment amounts and deductible credits.
• Documentation should demonstrate reasons for any primary-plan denial when seeking secondary payment.

Prior authorization requirement (cross reference)

See Section 6.1 and the Moda Health Member Dashboard for the full prior authorization list and procedures; providers must use those resources to determine authorization needs prior to delivering services.

• A full and updated list of services requiring prior authorization is maintained online.
• Contact Customer Service for behavioral health authorizations and status checks.

Prior authorization notice (Member Dashboard)

Services or supplies that require prior authorization are indicated on the Member Dashboard; failure to obtain required prior authorization may lead to denial or reduced benefit.

• Providers should verify authorization requirements and status via the Member Dashboard before scheduling services.
• If authorization is required but not obtained, members may face financial responsibility or penalties.

Out-of-network payment risk

Services received out-of-network may result in member responsibility for amounts over the maximum plan allowance and potential balance billing; providers should confirm network status and authorization to avoid this risk.

• If an out-of-network facility admission is nonemergent and not authorized, a 50% penalty up to $2,500 per occurrence may apply.
• Providers should verify member network and obtain prior authorization when using out-of-network providers.

Authorization required for nutritional therapy

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

• Initial visits may be covered per Schedule of Benefits, but authorization is required after the first 5 visits.
• Authorization limitations (time, number, frequency) will be specified in the authorization letter.

Prior authorization penalty and denial risk

If services using an out-of-network provider are not authorized in advance, a penalty of 50% up to $2,500 per occurrence is applied before regular plan benefits begin; unauthorized services may not be paid when a limitation or exclusion applies.

• The prior authorization penalty does not count toward deductible or out-of-pocket maximum.
• Emergency admissions are exempt from the penalty but must be authorized within 48 hours after admission.

Excluded services denied

When a service is otherwise excluded from benefits under Section 8 (e.g., cosmetic, experimental, infertility, naturopathic supplies), charges will be denied; prior authorization will not make excluded services payable unless a specific exception applies.

• Orthognathic surgery, experimental procedures, and infertility services are examples of excluded services.
• Providers should confirm exclusion status before submitting authorization requests.

Prior authorization required or risk of denial

If required prior authorization is not obtained for certain outpatient or inpatient services, charges may not be covered or a penalty may apply; providers must secure prior authorization per Section 6.1 before providing nonemergency services.

• Many outpatient services must be prior authorized; all nonemergency inpatient/residential care must be prior authorized.
• Failure to obtain prior authorization may result in full charge responsibility or application of a penalty.

Clinical trial coverage exclusions (items not covered outside trial)

Services or items that are not covered outside a clinical trial (including the investigational drug/device/service being tested) and items required only to provide or monitor the investigational item are not covered; providers must obtain prior authorization for clinical trial participation and document eligibility for approved trials.

• Clinical trial participation must be prior authorized and limited to approved trial types as described in Section 7.4.5.
• Items not covered outside the trial (investigational drug/device/service) are not covered even if provided within a trial.

DME and supply exclusions / docs

DME, appliances and supplies that are not medically necessary or that fall within exclusions (comfort/convenience, cosmetic, certain therapeutic devices, dental appliances, incontinence supplies, etc.) will be denied; providers must document medical necessity and obtain prior authorization when required.

• Replacement/repair covered only if DME was not abused and not used beyond specifications.
• If Moda requests, providers must authorize suppliers to release equipment order information and records.

Hospice eligibility

Hospice services provided to individuals who are not terminally ill are not covered and would be denied; hospice care must be for a terminally ill member with a written hospice treatment plan.

• Hospice must be Medicare‑approved and accredited; treatment plan must certify terminal illness.
• Services not included in the hospice treatment plan are not covered.

Skilled nursing exclusions

Skilled nursing facility charges are not covered if the admission occurred before policy coverage, if care is mainly for cognitive decline/dementia, or when care is routine/non-medical custodial care; providers must verify admission timing and medical necessity.

• SNF coverage requires a licensed facility and medically necessary rehabilitative care; limited days apply.
• Admissions prior to coverage effective date will be denied.

Cosmetic surgery not covered / reconstructive must be necessary

Cosmetic surgery is not covered; reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid. Providers must document medical necessity to support reconstructive claims.

• Reconstructive surgery that is partially cosmetic may be covered if medically necessary and prior authorized.
• Surgery for breast enhancement and implant replacement for cosmetic reasons is not covered except for gender dysphoria or post-mastectomy.

Transplant prior authorization timing (provider action)

Providers should obtain prior authorization for transplant candidates as soon as possible after identifying a potential transplant candidate; authorizations should include clinical documentation supporting medical necessity.

• Transplant authorization affects benefit accumulation and facility-related limits (Center of Excellence distinctions).
• Donor cost coverage rules depend on donor/recipient enrollment status and should be documented in authorization requests.

Vision prior authorization note

Some vision services may require prior authorization; in-network VSP providers will receive benefit authorization directly from VSP, and members must identify as VSP members when arranging in-network vision care.

• If members obtain vision services from in-network VSP providers without authorization, they may be responsible for payment and must submit reimbursement requests.
• Providers should verify VSP authorization and member eligibility before providing vision services.

Step therapy handling when submitted out of order

When a prescription for a step therapy medication is submitted out of order (Step 2 submitted before required Step 1 trial), the prescription will not be covered and the provider must prescribe the Step 1 medication unless an exception applies.

• Exceptions are allowed if Step 1 is ineffective, harmful, or not equivalent to the requested Step 2 medication.
• Providers may request a formulary exception with supporting documentation; urgent requests decided within 24 hours.

Medication prior authorization and dispensing limits

Certain prescription medications and/or quantities may require prior authorization; some specialty prescriptions may be limited to less than 30 days and new FDA-approved medications may be reviewed before coverage is set.

• Providers should check prior authorization and supply limits on the Member Dashboard.
• Self-administered injectable medications obtained in a provider office or clinic are not covered.

Experimental/Investigational Exclusion

Claims for experimental or investigational procedures and related expenses are excluded and will be denied; providers should not submit authorizations for procedures that meet the experimental/investigational definition without evidence of an applicable exception.

• Clinical trial coverage excludes the investigational drug/device/service being tested and items required only to provide or monitor the investigational item.
• Approved clinical trials are limited to specified funders or FDA investigational pathways; participation must be prior authorized.

Cosmetic Procedures Exclusion

Procedures performed primarily for cosmetic purposes (e.g., rhinoplasty, breast enhancement, liposuction, hair removal) are excluded and will be denied unless medical necessity and applicable exceptions are documented and prior authorized.

• Reconstructive surgery post-mastectomy and gender-affirming reconstructive procedures may be covered if medically necessary and prior authorized.
• Providers must provide documentation demonstrating medical necessity to avoid denial.

Missed appointment charges exclusion

Charges for missed appointments are excluded and may not be covered; providers should not expect reimbursement for missed-appointment fees under this policy.

• Members/providers should confirm billing policies for missed appointments directly with the provider, as the plan excludes such charges.

Naturopathic supplies & obesity exclusions

Naturopathic supplies, including herbal, homeopathic or nonprescription supplements, are excluded from coverage and claims for these items will be denied.

• These items are listed as exclusions in Section 8 and are not reimbursable under this policy.
• Providers should inform members that such supplies are not covered.

Medical necessity denials

Services or supplies that do not meet the plan's medical necessity criteria will be denied; providers must ensure documentation demonstrates that services are for treatment, consistent with diagnosis, standard in the service area, and the least costly safe alternative.

• The fact that a provider prescribes a service does not by itself make it medically necessary.
• Include clinical rationale and supporting records in authorization requests and claims to avoid medical necessity denials.

Claim submission timeliness and processing

Claims must be received no more than 12 months after the date of service; providers and members should submit timely claims and respond to requests for additional information to avoid denial for untimely or incomplete claims.

• If a claim is incomplete, Moda will notify and give time to supply additional information, but claims not received within 12 months will not be paid.
• Include required supporting documentation to prevent processing delays.

External review eligibility triggers

Final adverse benefit determinations involving medical necessity, appropriateness, health care setting, level of care, effectiveness, or investigational determinations may be eligible for independent external review; providers should assist members with documentation and forms when needed.

• Members must generally exhaust internal appeals before requesting external review, with specified timeframes for filing.
• Expedited external review processes are available for urgent care requests with accelerated timelines.

Continuity of care denial triggers

Continuity of care is not available if the member is no longer covered, the subscriber ends the policy, the provider moved out of the service area, the provider cannot continue care, or the contract ended for quality reasons and appeals are finished; providers should advise members to request continuity of care when applicable.

• Continuity of care must be requested and the provider must agree to follow prior contract terms and accept contractual reimbursement.
• Continuity ends at 90 days from the notice or earlier if the member ceases to meet continuing care criteria.