Prior authorizations and referrals
To help understand what services need prior authorization, Moda Health provides these prior authorization lists.
New! Submit your prior authorization request electronically
Please refer to these documents to help you determine if your patient needs a prior authorization:
- Commercial Plans Prior Authorization List - list of procedures requiring prior authorization
- Commercial Plans Always-Not-Covered List - list of procedures for members on a commercial plan that are procedures that are always not covered
- Medical Referral / Authorization Form- form to submit an authorization request or a referral of a patient to another provider or office
- Behavioral Health Authorization Form - form to submit an authorization request for Behavioral Health services, see more at the Behavioral Health support page.
Prior authorizations for Pharmacy
For help with prior authorizations for pharmacy, see the Pharmacy Support Page.
Prior authorizations for Behavioral Health
For help with prior authorizations for Behavioral Health procedures, see the Behavioral Health Support Page.
Support by type of procedure or location
- Inpatient Support
- Outpatient Support
- Imaging, Cardiology, and Musculoskeletal Support (eviCore)
- Therapies and alternative care (ASH)
Medical Necessity Criteria
Please refer to our Medical Necessity Criteria Support Page a complete list of medical necessity criteria.
Please refer to our Injectables/Infusion/Specialty Page for a complete list of medications requiring prior authorization and their criteria.
Prior authorization contacts
For help with referrals most procedures including Referrals, Inpatient Elective Procedures, Outpatient Selected Elective Procedures, Skilled Nursing Facility Long-Term Acute Care, Inpatient Rehabilitation, Home Health/Home Infusion, Hospice – Initial Evaluation and Service, Durable Medical Equipment (DME) and Transplants contact our Healthcare Service Team.
Phone: 888-474-8540 or 800-258-2037
Fax: 800-522-7004
Chemical Dependency and Mental Health authorizations
Phone: 855-294-1665
Fax: 503-670-8349
Expedited requests
If you need help with getting a request expedited, please call Healthcare Services at 888-474-8540 or 800-258-2037 or fax at 503-243-5105.
An expedited request is completed within 72 hours of receipt. Submitting an expedited request means that you are attesting that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.
Prior authorization data history
2023
- Medical and Behavorial Health - Prior Authorization requests (2023)
- Pharmacy - Prior Authorization requests (2023)
2022
- Medical and Behavorial Health - Prior Authorization requests (2022)
- Pharmacy - Prior Authorization requests (2022)