PPO FAQs
- What is a PPO plan?
- How will I benefit from using the PPO physicians and hospitals?
- How do I use the PPO when I need healthcare?
- Do all family members have to choose the same PPO provider?
- What if my family physician is not in this directory?
- What should I do in a medical emergency?
- How are my claims handled?
- What if my benefit plan does not cover a service that I have received from a preferred provider?
- How do I find out what my benefits will be when using PPO physicians and hospitals?
- What is the address for filing a claim?
What is a PPO plan?
A Preferred Provider Organization (PPO) plan is a type of health plan. A PPO contracts with specific physicians and hospitals to secure preferred rates for you and your covered family members. You can decide to visit a PPO provider any time medical care is needed. Should you choose a non-PPO provider, a lower level of benefit may apply. When you choose a PPO provider, you will receive quality medical care and the highest level of benefits. Moda Health contracts with several PPO networks to provide more physician choices and geographic coverage.
How will I benefit from using the PPO physicians and hospitals?
Using PPO physicians and hospitals will benefit you for the following reasons:
- You will be receiving quality healthcare from some of the area's most respected private practice physicians and hospitals.
- Your health insuranceplan will offer the highest level of benefits when you use PPO physicians and hospitals.
- You will save money through lower out-of-pocket expenses. Remember, participating preferred providers (physicians and hospitals) agree to accept preferred rates for services provided to Moda Health members like you.
- There is no additional paperwork. PPO physicians and hospitals bill Moda Health for you.
- Your PPO provider will assist with preauthorization requirements.
How do I use the PPO network when I need healthcare?
Follow the directions below:
- Select your physician or hospital from the correct PPO network in our find care directory.
- Identify yourself as a "PPO member" when you make your appointment (be sure to give your group and ID numbers).
- Show your ID card when you arrive.
- Savings are automatic, and the physician or hospital bills Moda Health directly.
Do all family members have to choose the same PPO provider?
No. Each family member may choose his or her own provider.
What if my family physician is not in this directory?
You can decide to visit a non-PPO physician; however, any allowable services will be paid at lower benefit levels and subject to the maximum plan allowance than if you visited a PPO physician. To find a PPO physician in the Moda Health network, visit our find care directory.
What should I do in a medical emergency?
In the event of an emergency, you are covered worldwide 24 hours a day, seven days a week. An emergency medical condition is defined as a condition producing symptoms severe enough that a person�s well-being is in serious jeopardy - as judged by any reasonable person with an average knowledge of health and medicine. Emergencies also apply to a fetus in the case of a pregnant woman.* In an emergency, you should proceed to the closest medical facility for care. In the case where a non-participating facility or provider is used for follow-up care to a medical emergency, lower out-of-network benefits will apply.
How are my claims handled?
If you use a PPO provider, the provider will bill Moda Health directly.
What if my benefit plan does not cover a service that I have already received from a preferred provider?
For services not covered by your health benefit plan, you will be responsible for paying the provider's fee.
How do I find out what my benefits will be when using PPO physicians and hospitals?
You will need to create a Member Dashboard account and then access this information online or refer to your Member Handbook, which also can be accessed in your Member Dashboard account . If you have further questions about a specific service, contact Moda Health Customer Service.
What is the address for filing a claim?
Send claims to:
Moda Health
P.O. Box 40384
Portland, OR 97240-0384
Please include the following information:
- Patient's name, identification number and group ID number
- Date of treatment
- Diagnosis
- An itemized description of services and charges
If the treatment is for an accidental injury, include a statement with the date, time, place and circumstances of the accident when you send us the physician or professional provider's bill.
*These answers reflect our standard contracts. Your contract may be different. Please refer to your Member Handbook for information about your specific plan.
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