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Eligibility Page

Birth Date (Age):
This is the patient/member's birth date. The age is calculated based on the date of eligibility being viewed.

COB (Coordination of benefits):
This field indicates if the member has other coverage. This includes other coverage through Moda Health Plans and other carriers. Please contact Moda Health customer service to verify.

Family coverage:
Description of the enrollment status of a subscriber.

Group #:
The number assigned to the entire employer group, labor union or trustee or parts thereof by the insurance carrier. Individual plan members may have a policy number.

Group name:
The name of the employer group, labor union or trustee.

Name:
This field lists the names of all the members (subscriber and dependents) covered under a given subscriber at a point in time. The list of names can change as the eligibility date changes.

Network:
This is the network name for the patient being viewed. Moda Health Plans contracts with physicians on several networks. To find out which Moda Health networks your physician contracts with, use the physician search.

Care provided by an out of network provider will be covered at a lower rate or possibly not covered at all depending on the plan.

Plan Effective Date:
This date reflects the patient's effective date on their current coverage. A patient may have different benefits prior to this date and also a different group and/or employer during the prior coverage. To check prior eligibility go to the Check eligibility for another date field.

Plan type:
This field contains a description of the type of plan and also informs you if this member's plan requires a referral for some services to receive the highest benefit.

PCP (Primary Care Physician):
The pcp listed is for the date of eligibility being viewed. See pcp history for a complete listing. For indemnity or PPO plans, this field will be blank.

Relation:
Description of the individual member's relationship to the primary subscriber. Domestic partners are sometimes listed as other and sometimes as husband or wife.

Subscriber:
For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder.

Subscriber ID:
The identification number assigned to the subscriber.

Term date:
The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage.

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Benefits Page

Authorizations:
The field identifies where to call for authorization of medical (non-pharmacy) services for this patient.

Birth Date (Age):
This is the patient/member's birth date. The age is calculated based on the date of eligibility being viewed.

Benefit Year:
The period designated for application of deductibles or specific types of benefits. Each year the deductible must be satisfied again or the benefits are again available.

Customer Service:
This field lists the phone number for medical offices or facilities' customer service questions. Patients should be directed to call the phone number listed on their ID card.

Deductible:
The portion of an individual's healthcare expenses that must be paid by the member in a given year before the insurance plan will start paying for treatment. Some plans have a family deductible. Once this family maximum deductible is met, the patient's deductible is considered to be met.

Dependent Age:
Maximum age a child dependent has coverage.

Domestic Partner:
Description of any domestic partner coverage available for this plan. Some plans offer this coverage, but may limit to same gender or opposite gender partners.

Group #:
The number assigned to the entire employer group, labor union or trustee or parts thereof by the insurance carrier. Individual plan members may have a policy number.

In Network:
In network benefits and amounts apply when a patient/member receives medical care using a physician in the network assigned to their medical plan. MBT lists each patient's network. The "physician search" can be used to see if a physician is part of a specific network.

Lifetime Max:
Lifetime maximum dollar amount benefit under a plan.

Mental Health/Chemical Dependency:
This field lists that appropriate contact information for mental health services for this patient.

Network:
This is the network name for the patient being viewed. Moda Health Plans contracts with physicians on several networks. To find out which Moda Health networks your physician contracts with, use the physician search.

Office copay/coinsurance:
The insured patient's share of the total medical bill, usually expressed as a specific dollar (copay) or percentage amount (coinsurance) paid for a given service, product, or treatment. For example, the patient might pay $10 for each visit to a doctor's office, or 20% for hospitalization. A copayment is generally due at the time of the treatment or service. The terms copayment and coinsurance are often used interchangeably despite their differences.

Out of Network:
Out of network benefits and amounts apply when a patient/member receives medical care using a physician not in the specified network that is assigned to their medical plan. Generally, the subscriber will pay a higher cost for services when they receive care out of network. Some plans (such as managed care) do not have out of network benefits.

Out-of-pocket (OOP):
The amount a member pays toward copays and coinsurance. Certain expenses do not apply to the out-of-pocket. Some plans have a family out-of-pocket maximum.

Plan type:
This field contains a description of the type of plan and also informs you if this member's plan requires a referral for some services to receive the highest benefit.

Pre-existing Months:
Number of months an individual must wait for coverage of physical and/or mental condition that existed prior to the issuance of his or her insurance policy.

Referrals:
This field identifies where to call regarding referrals for this patient.

Remaining:
The amount remaining to be satisfied of the deductible and out-of-pocket.

Student Age:
Maximum age a student may be covered.

Subscriber ID:
The identification number assigned to the subscriber.

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Claims & Claims Detail Page

Allowed:
Dollar amount for which the maximum amount payable for specific services is listed.

Birth Date (Age):
This is the patient/member's birth date. The age is calculated based on the date of eligibility being viewed.

Claim number:
The claim number assigned by Moda Health. Only claims for your tax identification number (TIN) will show. Claims are listed with the most current first. On paid claims, the claim number is a link to a claim detail screen that includes payment information.

Charge:
The amount charged by the physician or provider for service(s) performed.

Claim Paid Under Group # (internal only):
Which group number was the active group number for the member at the time of service.

CPT/Rev code:
The code used for billing. This field will usually be a CPT code. Some hospital charges could show a Revenue code instead.

Copay
This shows the patient's responsibility on the remaining covered charges after the plan's benefits have been applied.

Dates:
The date of service or date span for the claim.

Deductible:
The amount of the charge applied toward the patient's deductible. Not all plans have deductibles.

Disallowed/Reason:
The amount of the charge, if any, that is being denied. The reason codes will usually describe the disallowed reason.

Paid:
The amount paid by the health plan toward a claim to the provider.

Patient acct. (patient account number):
The account number assigned to the patient by the provider's office.

Provider:
The physician or facility who delivered the service. The tax id number of the provider is also listed for your reference.

Provider discount:
This is an adjustment made by participating providers and is not a patient responsibility.

Provider withhold:
Under the applicable provider contract, reimbursement may be subject to a withhold.

Pt Resp (patient responsibility):
The total of disallowed charges, copayments, and charges applied to the deductible.

Referral Inquiry Page

Auth visits or LOS:
Auth visits is the number of office visits, therapy visits or surgery procedures approved. If 99 is listed this means that there is no limit to the number of visits during the date span of the referral.

LOS refers to the length of stay (number of nights) approved for an inpatient stay. Please note that the night before surgery is not covered unless specifically indicated.

Birth Date (Age):
This is the patient/member's birth date. The age is calculated based on the date of eligibility being viewed.

Comments:
Several types of information may be found under comments.

1. The name of the hospital will be listed when the surgery/procedure has been authorized on an outpatient basis.
2. The name of the facility or provider that is not currently in the Moda Health database will be listed in the comments column. Please note that this does not automatically indicate that out of network services have been authorized. Authorized or not authorized information will be found under the "status" column.
3. Information not clearly described in the services column, i.e. bilateral (bilateral procedure).
4. The words NO SG OPT (No Surgical Option) will be listed if the Primary Care Physician wants to be contacted with findings prior to the specialist requesting authorization of treatment with Moda Health.

NO SG OPT means that the specialist does not have the PCP's permission to request a authorization of a surgery or a procedure without first consulting with the Primary Care Physician.

If NO SG OPT is not in the comments field, the specialist can request authorization of a surgery or procedure through Moda Health without consulting back with the Primary Care Physician.

Date span:
This shows the valid dates for the referral or authorization. If the date of service that you are inquiring about does not fall within this date range, please contact the referral customer service unit for assistance. Remember that extension requests for referrals must come from the patient's current primary care physician.

Diag. Code:
The 3 to 5 digit diagnosis code is listed under this field. Up to 5 diagnosis codes may be listed.

Status:
The 4 status options are in process, partially authorized, below the line diagnosis or not authorized.

In process means that the status of the referral/authorization is pending. In process should be a temporary state, please contact Moda Health referral unit if the status is not updated within a 24 hour period.

Items in italics indicate that a referral or authorization is in process and has not been completed.

Partially authorized indicates that a portion of the procedures or the length of stay requested has not been approved. You will need to contact Moda Health referral customer service unit for details.

Below the line diagnosis shows to indicate that a referral has been authorized but the diagnosis submitted has benefit limitations under the Oregon Health Plan. A 3 visits limit is authorized for below the line diagnoses.

Not authorized means you will need to contact the Moda Health referral customer service unit if you would like information on the reason the service was not allowed.

Items highlighted in red under the status column are done so that these items are brought to your attention. Not authorized or partially authorized items are an example of something we have highlighted in red.

Referred to provider or hospital:
The provider or facility that has been authorized. In the case where a referral or authorization has been disallowed, the provider who requested the service is listed.

Services:
What services have been approved or denied. The field may contain a CPT code, HCPC code or a description of service such as an office visit. This field will also show what is included in the scope of a referral, i.e., diagnostic procedures, office treatment. Any needed clarification of the procedure will be located under comments.

Subscriber:
For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder.

Subscriber ID:
The identification number assigned to the subscriber.

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