PERS ODS Advantage PPORX (PPO) medical appeal and grievance procedure
Our goal is to provide you with coverage and services that always exceed your expectations. However, if you have concerns or problems with any part of your benefits, care or service, as a PERS ODS Advantage PPORX member, you have the right to file a complaint.
There are two types of complaints: appeals and grievances.
Appeal
You can make an appeal if you disagree with a decision to deny a request for healthcare services or payment for services you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for an item or service you think you should be able to receive. Our Annual Notice of Changes — Evidence of Coverage for the PERS ODS Advantage PPORX plan Chapter 9 includes an explanation of appeals, including the process involved in making an appeal.
Grievance
A grievance is a type of complaint you make about Moda Health or one of our network providers, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. Our Annual Notice of Changes — Evidence of Coverage, Chapter 9 includes more information about a complaint and how to make one.
More information
Appointment of Representative form: Use this form to name a relative, friend, advocate, doctor or anyone else as your appointed representative. This person may request an organization determination or file a grievance or appeal on your behalf. If you want someone to act for you, then you and that person must sign the Appointment of Representative form, giving that person legal permission to act as your appointed representative.
If you have questions or need help with your appeal or grievance, please call member services. You can mail your appeal or grievance to:
Moda Health Plan, Inc.
Attn: ODS Advantage Appeals
P.O. Box 40384
Portland, OR 97240-0384
You may also fax it to: 503-243-5105
For a report on the number of PERS ODS Advantage PPORX grievances and appeals, please call member services.
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