How do I know what plan I have?

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Pioneer Network: The Pioneer Network is a network for members on individual, small and large group plans. It was developed to provide cost-effective, coordinated care for residents of the Anchorage, Mat-Su, and Kenai Peninsula boroughs. Pioneer offers three benefit levels (tiers) of healthcare: Tier One. 17-nov-2016 - Esplora la bacheca 'vestiti tumblr' di Mariana Patricelli su Pinterest. Visualizza altre idee su vestiti, abbigliamento, vestito dolce. Francine Bishop Making Social Media Simple! I teach business owners how to use social media. No jargon, just simple actions to grow. OR I manage it for them, on their behalf.

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.

Can I choose a primary care physician (PCP) or specialist online?

Yes, you can select a primary care physician (PCP) online. To find a physician in your area, go to our find care directory. If you're signing up for a new PCP, be sure to contact the physician's office to verify that he or she is accepting new patients. When you have selected a PCP who is accepting patients, contact Moda Health Customer Service or register online. A new ID card will be sent to you within five to 10 working days. You can change PCPs up to two times per year. Remember, your new PCP is effective at the beginning of the next month.

You also can find specialists online through the find care directory. Depending on your plan type, you may need a referral to see them. If that is the case, your PCP will refer you for specialty care, including both physician and hospital services.

What do I do if my doctor or dentist no longer participates with Moda Health and I want to continue seeing him or her?

Medical: 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.

Dental: Under most Moda Health plans, you can see any licensed dentist whether his or her status is participating or not. Please contact Moda Health Dental Customer Service for assistance with a provider search and for additional questions.

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.

How do I add or drop a member of my family on my plan?

To add or drop a dependent on your plan, you will need to contact your employer's HR department. The only time Moda Health will drop a dependent automatically is when he or she exceeds the age limit.

I have other group coverage - will Moda Health coordinate benefits?

Generally, yes. It is important that you notify us of your other group coverage on your medical and dental enrollment forms so that we know to coordinate benefits. Please contact Moda Health Customer Service for more information.

Generally, yes. It is important that you notify us of your other coverage on your medical enrollment form so that we know to coordinate benefits. Please contact Moda Health Customer Service for more information.

My co-worker has a question, but he doesn't speak English very well. Can you help?

Yes, we can help.for all medical, pharmacy and dental plans, and for Oregon Health Plan dental and medical customers. Simply have your co-worker contact Moda Health Customer Service, and one of our representatives will coordinate the services of an interpreter over the phone.

Yes, we can help with all medical and pharmacy plans. Simply have your co-worker contact Moda Health Customer Service, and one of our representatives will coordinate the services of an interpreter over the phone.

What if I'm not sure if I have medical or dental 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?

Congratulations on your new arrival! You have the option of adding your baby to your plan. You must add your baby within 31 days of his or her birth. You will need to contact your employer as soon as possible so that the baby can be enrolled on the group plan. If you have purchased an individual plan, please contact Moda Health Customer Service.

Congratulations on your new arrival! ! You have the option of adding your baby to your plan. You must add your baby within 31 days of his or her birth. If you have purchased an individual plan, please contact Moda Health Customer Service.

How do I order an ID card?

An ID card will be sent to you upon enrollment in a Moda Health plan. To order a new medical or dental ID card, please log on to Member Dashboard and select 'Request ID cards' from the member shortcuts panel. You also can contact Moda Health Customer Service. If you have purchased an individual dental plan, please contact Moda Health Customer Service.

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How do I read my Explanation of Benefits (EOB)?

We have provided an Explanation of Benefits (EOB) sample for you to read.

What is the address for filing a claim?

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

Please include the following information:

• 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:

1. a percent at or above what Medicare would allow for the service;
2. a percentile of fees commonly charged for a given procedure in a given area, based on a national database;
3. acquisition cost;
4. 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.

I can't find my provider, is there a list of providers that have ended their contract with Moda Health?

Yes, please visit our list of Moda Health termed providers.

What steps do I take if I need Durable Medical Equipment (DME)?

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If you are a member with new or recurring DME needs, just follow these easy steps to search for an in-network DME provider:

1. 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.
2. Or you can log in to your Member Dashboard account.
3. Go to Find Care and choose the “Durable Medical Equipment” option under the Specialty drop-down menu.
4. Enter your ZIP code and Search.
5. 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.

Moda Health is pleased to offer its members a variety of plan types to help fit their healthcare needs. Below are the 2021 medical provider networks for our Oregon individual, small group, and large group members. Members save money by seeing in-network providers. Check medical plan summaries to see which medical network is included with each plan.

Connexus Network

This is one of the largest preferred provider organization (PPO) medical networks in Oregon. It includes thousands of primary care providers and specialists working together with Moda Health to help keep members healthy. Groups located anywhere in Oregon can choose a plan with this network. Members can see in-network providers in all counties in Oregon and some areas in Washington and Idaho.

Health systems participating in Connexus include:

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Synergy Network

The Synergy network offers an integrated care experience to members living throughout the state, as well as border counties in Washington and Idaho. This network connects members to a Moda Medical Home or PCP360, who work together to coordinate care, and keep members feeling their best.

Health systems participating in Synergy include:

Synergy plans are available to small and large employer groups.

Beacon EPO Network

The Beacon EPO Network offers a personalized care experience that gives members quick access to quality care at an affordable cost. This network is available to individuals who purchase health coverage directly from Moda or through the federal marketplace exchange, and reside in Clackamas, Clatsop, Columbia, Coos, Curry, Hood River, Jackson, Josephine, Multnomah, Tillamook, Wasco, Washington or Yamhill counties. Beacon EPO plans are only available to members who reside within the Beacon EPO service area. Beacon EPO members are required to select an in-network Primary Care Physician.

Health systems participating in Beacon EPO include:

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To choose an in-network primary care provider (PCP), members can go to ShopModaPlans.com to search for a Beacon EPO provider or confirm that their PCP is in-network.

Affinity EPO Network

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The Affinity EPO Network offers a personalized care experience that gives members quick access to quality care at an affordable cost. This network is available to individuals who purchase health coverage directly from Moda or through the federal marketplace exchange, and reside in Baker, Crook, Gilliam, Grant, Harney, Jefferson, Klamath, Lake, Lane, Malheur, Marion, Morrow, Polk, Sherman, Umatilla, Union, Wallowa or Wheeler counties. Affinity EPO plans are only available to members who reside within the Affinity EPO service area. Affinity EPO members are required to select an in-network Primary Care Physician.

Health systems participating in Affinity EPO include:

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To choose an in-network primary care provider (PCP), members can go to ShopModaPlans.com to search for an Affinity EPO provider or confirm that their PCP is in-network.

Please note: Beginning Jan. 1, 2019, all Oregon Individual plans including Beacon EPO and Affinity EPO, will be connected to an Exclusive Provider Organization (EPO) network. Individual EPO plans do not have out-of-network benefits, so it is important that your patients are referred to providers within the Individual plan and network in which the patient is enrolled.

Please review your patient's Moda member ID card and check our provider directory Findcare, to ensure care is referred to other in-network Beacon EPO or Affinity EPO providers. Services provided to Moda Individual members by out-of-network providers will result in higher costs for patients enrolled in these plans.