Appeals and grievances

Filing a complaint

If you have concerns or problems with any part of your benefits, care, service or prescription drugs; you can file a complaint. Appeals and grievances are the two types of complaints you can file.

Filing an appeal

If you do not agree with a decision we have made, you can make an appeal (a request to change the decision) within 60 days. You can do this for decisions about services and payment. You can also request that we cover an item or service that is not in your plan.

If you need to ask for a review of a medical care coverage decision made by our plan, you or your provider may do one of the following:

• Call 877 299-9062
• Submit a written request and fax to 503 412-4003
• Submit a written request and mail to:

Moda Health
Attn: Medicare Appeal and Grievance Unit
P.O. Box 40384
Portland, OR 97240-0384

For pharmacy appeals:

• Complete our online Prescription drug redetermination request form
• If you prefer to mail or fax your request, you may complete this prescription drug redetermination request form.

Learn more about making a pharmacy appeal in your Evidence of Coverage.

If your health requires a quick response, you must ask for a “fast appeal.” For an expedited appeal, you or your provider may do one of the following:

• Call 866-796-3221 (voicemail only) and leave us a message with your name, plan ID and details of your request.
• Submit a written request and fax to 503-412-4003, Attn: Medicare Expedited Appeal and Grievance Unit
• Submit a written request and mail to:
  
  Moda Health
  Attn: Medicare Appeal and Grievance Unit
  P.O. Box 40384
  Portland, OR 97240-0384

Please make sure to write “expedited appeal” on your request.

Learn more about making an appeal in your Evidence of Coverage.

Filing a grievance

If you are not satisfied with us or one of our providers, you can file a grievance. A grievance is not for coverage or payment. Learn more about filing a grievance in your Evidence of Coverage.

Need help filing an appeal or grievance? Please call our Moda Health Customer Service at 503-265-4762 or toll-free at 877-299-9062. TTY users, dial 711. Customer Service is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through March 31. (After March 31, your call will be handled by our automated phone system Saturdays, Sundays and holidays.) You can also find out how many appeals, grievances and exceptions we have received. Just ask us.

If you choose to mail your grievance, send it to:

Moda Health Plan, Inc.
Attn: Moda Health Medicare Appeals
P.O. Box 40384
Portland, OR 97240-0384

Appointing a representative

You can assign someone you trust to request authorization, or file a claim, grievance or appeal. To do this, please complete our Appointment of Representative form. You will need to have the person you appoint sign the form. You can submit this form with your appeal or grievance request.

Filing a complaint with Medicare

We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online complaint form.