Moda Health Plan, Prior Authorization

Moda Health Plan, prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Prior authorization requirements vary by line of business and service type. Moda provides service-specific authorization lists and an electronic submission path through Benefit Tracker. For commercial medical services, some categories are routed to eviCore or Prime Therapeutics Management, and elective inpatient admissions require pre-authorization. Urgent/emergent hospital admissions must be reported within 48 hours. Moda states that failure to obtain required authorization may result in non-payment and provider liability.
• Requirements vary by plan and service category.
• Some authorization workflows are delegated to external vendors such as eviCore and Prime Therapeutics Management.
• The provider manual and authorization page include plan-specific phone numbers and fax numbers for certain products.
• Authorization does not guarantee payment.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3

How to submit prior authorization requests

• Electronically through Benefit Tracker

• Through eviCore healthcare provider portal for advanced imaging and musculoskeletal services

• Through Prime Therapeutics Management provider portal for selected infusion/injectable drugs

• Phone/fax for some service categories listed in the authorization table

• Submission resource 1

• Submission resource 2

• Submission resource 3

Information commonly required

• Verify member eligibility and benefits before requesting authorization
• Verify the requested provider/facility is in-network
• Verify any contract-specific pre-authorization requirements
• Use Moda Health Medical Necessity Criteria, MCG, or CMS guidelines as applicable
• For urgent/emergent admission, notify Moda Health within 48 hours

Turnaround notes and caveats

• Moda’s member-facing transparency page states prior authorization requests are responded to within 2 business days, with an additional response no more than 15 days after information is requested if more information is needed.
• Requirements vary by plan and service category.
• Some authorization workflows are delegated to external vendors such as eviCore and Prime Therapeutics Management.
• The provider manual and authorization page include plan-specific phone numbers and fax numbers for certain products.
• Authorization does not guarantee payment.

Provider resources

• Medical provider contact us (official)
• Referral and Authorization Guidelines (official)
• Commercial Provider Manual (PDF) (official)
• Medicare Advantage Provider Manual (PDF) (official)
• Provider billing and claims | Moda Health Idaho (official)

Sources