Member FAQs
- How do I know what plan I have?
- Can I view my plan summary and benefits online?
- What if my doctor no longer participates with Moda Health and I want to continue seeing him or her?
- Do I have to call customer service to update my account or can I do it through the website?
- I have other group coverage - will Moda Health coordinate benefits?
- My co-worker has a question, but he doesn't speak English very well. Can you help?
- What if I'm not sure if I have medical eligibility?
- How do I sign up my new baby for a plan?
- How do I order an ID card?
- How do I read my Explanation of Benefits (EOB)?
- How do I file a claim?
- How does Moda Health determine the allowable amount for medical services and procedures?
- What if the answers to my questions are not here?
- What steps do I take if I need Durable Medical Equipment (DME)?
- What is DME?
How do I know what plan I have?
The type of plan you have and what network you can use is printed at the top of your ID card as well as on the cover of your Member Handbook. You can access your Member Handbook and other account information by logging in to your Member Dashboard account.
Can I view my plan summary and benefits online?
Yes, you can view your summary and benefit information online by accessing your member website, Member Dashboard. You also can download your Member Handbook from Member Dashboard to view this information.
What do I do if my doctor no longer participates with Moda Health and I want to continue seeing him or her?
Your plan may have a continuity of care provision that will enable you to continue care with the physician for a limited period of time. If continuity of care applies to your plan, it will be described in your Member Handbook. You also can contact Moda Health Medical Customer Service for information.
Do I have to call customer service to update my account or can I do it through the website?
Please call our Customer Service team to update your account but note that some employers share that data with us, so we recommend contacting your HR group too if you are on plan from your employer.
I have other group coverage - will Moda Health coordinate benefits?
My co-worker has a question, but he doesn't speak English very well. Can you help?
What if I'm not sure if I have medical eligibility?
To verify your eligibility, you or your provider should contact Moda Health Customer Service. Your provider also can check your eligibility by visiting our website and logging on to Benefit Tracker. Providers must be participating in our free Benefit Tracker program to check your eligibility online.
How do I sign up my new baby for a plan?
How do I order an ID card?
How do I read my Explanation of Benefits (EOB)?
We have provided an Explanation of Benefits (EOB) sample for you to read.
How do I file a claim?
Medical claims
You can access claims forms by logging in to your Member Dashboard
Please include the following information:
Once your claim is ready, please send to:
Medical claims
Moda Health
P.O. Box 40384
Portland, OR 97240-0384
Dental claims
Moda Health
601 S.W. 2nd Ave.
Portland, OR 97204
Pharmacy claims
Moda Health
P.O. Box 40168
Portland, OR 97240
Major medical groups, please submit your pharmacy claims to:
Moda Health
P.O. Box 40384
Portland, OR 97240-0384
- Patient's name, identification number and group ID number
- Date of treatment
- Diagnosis (medical only)
- 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.
How does Moda Health determine the allowable amount for medical services and procedures?
Moda Health uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures.
MPA is the maximum amount that Moda Health will reimburse physicians and providers. For an in-network physician or provider, the maximum amount is the amount the provider has agreed to accept for a particular service.
For service by an out-of-network physician or provider, Moda Health will process charges for services as follows: the maximum allowable amount is the lesser of the amount payable under any supplemental provider fee arrangements we may have in place and a plan's standard allowable amount. Depending on the plan you have, the standard allowable amount may be based on one of the following:
- a percent at or above what Medicare would allow for the service;
- a percentile of fees commonly charged for a given procedure in a given area, based on a national database;
- acquisition cost;
- a percent of billed charges
Check your member handbook to determine how MPA is calculated for your particular plan.
For services provided by an out-of-network physician or provider, the amount above the MPA is the patient's responsibility. Depending on the plan, provisions deductibles and coinsurance may apply.
Please call Moda Health Medical Customer Service if you have any additional questions or concerns. We will be happy to help answer your questions.
What if the answers to my questions are not here?
If you can't find answers to your questions here, we offer other options on our website where you might find the information you're looking for. For instance, your Member Handbook outlines your plan details. You can access your Member Handbook by logging on to Member Dashboard. You also can contact your benefits department for more information or call or email the Moda Health Customer Service team.
What steps do I take if I need Durable Medical Equipment (DME)?
If you are a member with new or recurring DME needs, just follow these easy steps to search for an in-network DME provider:
- Simply call the medical customer service number on the back of your member ID card to find out which providers offer the Durable Medical Equipment you need.
- Or you can log in to your Member Dashboard account.
- Go to Find Care and choose the “Durable Medical Equipment” option under the Specialty drop-down menu.
- Enter your ZIP code and Search.
- This will bring up the list of DME providers. Preferred providers will have a DME badge icon next to the networks where they are available.
What is DME?
DME is equipment and related supplies that primarily help members manage a medical condition. DME includes things like breast pumps, CPAP, wheelchairs, walkers, oxygen, and diabetic or ostomy supplies. They are durable because they last a long time. They don't get used up like medical supplies.
Plans may cover the rental charge or DME (but not exceed the purchase price). Members can work with their provider to order their prescribed DME.
Questions?
Please see your Member Handbook to determine what is covered by your benefits.
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
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Hello.
We have exciting news to share. ODS is changing its name to Moda Health.
Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.
Together, we can be more, be better.
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