Forms and documents

Documents/guides

• Gender-confirming care - overview of gender-confirming care access to medical, surgical, behavioral health and additional support services
• How to read an EOB – use this guide to understand the information in an explanation of benefits (EOB). You can access EOBs in your Member Dashboard.
• Transparency in coverage - details about how we process claims
• Preventive services for adults - list of routine exams, immunizations and screenings for members age 18 and older
• Preventive services for children - list of routine exams, immunizations and screenings for members under the age of 18

Forms

• Appeal form – submit an appeal if you disagree with a claim/EOB
• COVID-19 OTC at home test medical member reimbursement form - claim form for COVID-19 at home tests, See our COVID FAQ page for more details.
• Coordination of benefits - form to allow additional benefits from other coverage a member may have
• Medical claim form – submit a medical claim manually using the mailing address and fax number on the form
• Pharmacy claim form - submit a pharmacy claim manually using the mailing address or fax number on the form
• Protected Health Information (PHI) Disclosure Authorization – Authorize Moda Health to use/disclose information about a member (see instructions for more details)
• Transition of care - new enrollee transitioning on to a new plan or an existing member whose provider network has changed
• Transición de la atención - nuevo miembro inscrito que pasa a un nuevo plan o continuidad de la atención: miembro existente cuya red de proveedores ha cambiado