Moda Health

Moda Health reviewed and responded to the appeal in April We advised the member that when the office called, they advised Moda Health that they were an in-network provider for the members plan There was no mis information provided by Moda Health Thank you

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to meI believe that the Revdex.com's intervention in this matter speeded it's resolution, as I received a call from MODA after they had received the complaint and they immediately instigated the refundThis after nearly months of non-productive phone calls and non-action by MODAThank you for your efforts.Sincerely, [redacted] ***

Dear Ms [redacted] : This is in response to the complaint number [redacted] , dated February 26, In which you informedus of [redacted] ***’s issues regarding receiving conflicting information about the date premium paymentsare due and also the inadequate customer service Ms [redacted] feels she has received from Moda Health Ms***’s complaint states that when she was shopping around for health insurance at the end ofthe Moda Health salesperson advised her that there was a day grace period for members thatbought their policy directly from Moda Health and days for customers that bought their plan throughthe Healthcare MarketplaceWhen she logged into the Moda Health ebill system on February 22, 2016to make February 2016’s premium payment, there was no longer a tab to make the paymentShecontacted Moda Health medical customer service and was advised that it is over the day grace periodfor payment, therefore there is no option to pay onlineShe was also informed the policy for her and herfamily may be cancelled due to non-paymentShe felt that the customer service representative wascondescending and “snarky.” She would like to know if her medical coverage is still active and if it is notshe would like a receipt of her payment for February not being processed The Be Protected Preferred Provider Organization (PPO) Plan requires all premium payments due inadvanceModa Health will allow a 20-day grace period after the premium due dateIf payment is notreceived within the grace period, the policy will end after a 10-day advance noticeCoverage will end onthe last day of the coverage period for which premiums were paidPlease review the attached BeProtected PPO Plan handbook pages 47-that explain eligibility and premium payments On February 22, 2016, Ms [redacted] contacted Moda Health medical customer service after not being ableto make February’s premium payment online and was advised that the due date for premium paymentis the 20th of each monthShe gave the representative the payment information to process February2016’s premium paymentThe representative told Ms [redacted] that they would call her back to tell her whether or not Moda Health was able to accept the premium payment made for February as itwas past the day grace period and also if we would be able to continue her family’s coverage On February 25, 2016, the premium payment in the amount of $was approved and processed forthe month of February The Moda Health medical customer service representative contacted Ms[redacted] on February 25, 2016, and let her know that we did take the premium payment for February 2016and her and the [redacted] family currently have active medical coverage and will not be terminated for nonpayment.Ms***’s next premium payment in the amount of $is due prior to March 20, We have reviewed your payment history with our billing and eligibility departmentYou are now ablemake payment for the month of March through the ebill system up until March 20, as theMarch bill is currently open We understand that the information Ms [redacted] received when enrolling may have been conflicting, wealso appreciate the comments made in the complaint and look forward to providing her better customerservice in the future If we can be of additional assistance, please contact our office at, locally 503-243-or,nationally 1-877-605-3229, and Telecommunications Relay Service at Sincerely,Peter C.Appeal CoordinatorModa Health Quality Programs

We received the initial concern This member also filed an insurance division concern We have days to respond to the insurance division and once we do this, we will forward a copy to your office

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to meThe issue is when contacting Moda Health they were giving me a different timeline on the return of the fundsThe first time it was not established this would be the process, the second time it was noted it would take to weeks to process the information, and the last time confirmed this informationIf they had noted this during the first conversation of how long the potential turnaround time was for processing it would not have been an issueThe issue is I was given a different story every time I contacted themIf their customer service reps can give the same information every time that would be greatSincerely, [redacted]

This concern was reviewed by the dental claims and fraud unit It is our position that no privacy violation occurred When Ms [redacted] contacted the customer service unit, the customer service representative followed the caller authentication processMs [redacted] 's authorization is not needed for her dental office to send us a dental claim for processing or for us to send a denial back to the office Our records indicate that the dental provider sent the claim to [redacted] electronically There was no group number, group name on the claim form, but the office did provide her name, address and date of birth As Ms [redacted] had coverage with [redacted] previously, the claim was processed under the previous coverage since this is the only record that we have for the member The claim was processed correctly and an explanation of benefits was sent to the address on file and what was provided by the office The claim denied due to eligibility While we appreciate and understand the concerns that Ms [redacted] expressed in her complaint, [redacted] followed correct procedures in regards to this complaint

September 25, Revdex.com Attention: [redacted] PO Box DuPont, WA Member: *** [redacted] ID#: [redacted] Subscriber: [redacted] Group#: [redacted] Complaint ID #: [redacted] Dear Ms***: This is in response to the Revdex.com (Revdex.com) complaint ID #: [redacted] received at Moda Health on September 21, regarding a premium refund for Ms [redacted] ’s previous individual medical policy with Moda Health We reviewed the complaint filed by Ms [redacted] We will provide you with details regarding the termination On August 24, 2015, Ms [redacted] contacted Moda Health customer service to remove her son, [redacted] , from her Oregon Individual Standard Bronze Plan effective August 31, On August 25, 2015, Ms [redacted] contacted Moda Health customer service to remove herself from her Oregon Individual Standard Bronze PlanShe also indicated, during this call, that her spouse should be the only one left on the accountA request was sent by the customer service representative to our billing and eligibility department to terminate the policy for an August 31, term date and to create a new policy for her husband On September 1, 2015, Ms [redacted] contacted Moda Health customer service about the termination of her plan and she was advised to cancel the payment for her policy on her eBill accountShe was told that her spouse will be going on his own policy and a new account would need to be created for himOn September 1, 2015, the full premium for Ms [redacted] s account was drafted, however did not post until September 2, On September 4, 2015, Ms [redacted] contacted Moda Health customer service stating that the premium amount of $was draftedAccording to the Moda Health billing and eligibility department, since a termination was entered previously for Ms [redacted] ’s son [redacted] on the same account our database would not allow to terminate the policy before September 1, Based on the call, the policy was terminated correctly with a termination date of August 31, Ms [redacted] was informed that she would receive a refund in the amount of $however it will take a couple of weeks for the refund to be processed and a check issued On September 18, 2015, Ms [redacted] emailed Moda Health stating that she had not received her refund check and inquired when the check was mailedModa Health contacted Ms [redacted] and stated that the check was not issued and it could take two to three weeks Ms [redacted] ’s refund was processed and issued on September 24, Ms [redacted] should receive her check in the mail with business days If we can be of additional assistance, please contact our office at, locally [redacted] or, nationally [redacted] , and Telecommunications Relay Service at *** Sincerely, Lowanna N Appeal Coordinator II Quality Programs

If Ms [redacted] disagrees with the processing of her claim, she may appeal the decision with Moda Health Appeal rights are listed in her member handbook Thank you

We are unable to review this request This member was receiving a subsidy on her medical plan Dental plans don not have a subsidy its just a flat payment

In order to respond to this concern, we need a member identification number or claim number. Thank you.

This is in response to your letter dated August 2, in which you informed us of Ms [redacted] complaint regarding a refund on his individual policyMs [redacted] states in her complaint that during the month of July she received a bill from Moda Health and was told that she had a premium creditWhen she went to fill a prescription on July 23, 2016, she was informed that she did not have insuranceShe called Moda Health and was informed that she needed to pay $Ms [redacted] explains that she did not understand why she was being billed the $but sent in a paymentShe received another letter stating that her coverage was terminated as of June 1, When she called Moda Health again she was informed that her payment was not posted and her policy was terminated June 30, for non-payment of July’s premiumShe states when she made phone calls on July and 26, she was informed that she could make the payment for JulyMs [redacted] was eligible with Moda Health as of March 1, Moda Health did not receive Ms [redacted] July premium; therefore, Moda Health sent a delinquent notice to Ms [redacted] on July 9, (enclosed), stating that her premium in the amount of $must be received in our office no later than July 20, to ensure continuous coverageMs [redacted] policy terminated on July 26, with a termination date of June 30, as her July premium was not received by the payment due dateOn July 27, 2016, Ms [redacted] called Moda Health’s customer service stating that she received a bill for $Moda Health’s customer service representative explained that her premium due was $because she had an overpayment on her policy from the payment posted for February Ms [redacted] hung up on the customer service representative before she was informed that Moda Health would need to see if the account could be reinstated as the premium was due on July 20, Ms [redacted] premium payment was received on July 28, Ms [redacted] called Moda Health on August 2, and was informed that her policy was terminated as her July premium was not received in time, and the recent payment made on July 28, was being refunded and she would receive a refund check within 2-weeksWe reviewed Ms [redacted] complaint and verified on August 8, the premium refund request is in process for the amount $1,and a refund checkwill be mailed to Ms [redacted] in 2-weeksThis issue has been resolved with Moda Health, and we would like to apologize to Ms [redacted] for any inconvenience this may have causedIf we can be of additional assistance, please contact our office at, locally 503-243-or, nationally 1-877-605-3229, and Telecommunications Relay Service at Sincerely,

We apprecaitge the comments and we will share them with the privacy/fraud unit

Complaint: [redacted] I am rejecting this response because: I did call and verify my benefits with MODA before my DrappointmentThey are claiming they have no record of the callI have no way of proving this, but me AND pearl women's center called to verify benefits with themThis violates my good faith as a customer Sincerely, [redacted] ( [redacted] )

They have a very obsolete system when it comes to processing premiums and other paymentsNo understanding and a 1% margin for errorThey would rather not take your money and deny health coverageI spoke to different customer service representatives and only one was nice and reassuring, and willing to take the time and effort to try and rectify the situationunfortunately that customer service representative was only able to do little do to the fact the accounting is a separate department and they don't take callsSo we were not able to have "eyes" on the situation and see why my payments I made were not going through

Moda is a messI pay premium prices that keep going up for services that keep disappearingThey switched networks to Beacon which has limited providers, terrible communication, lost my only doctor in the switch and not enough time to find a new insurance plan before the open enrollment endedIn general it's hardwhen you have to pay for an individual plan but now it's really uselessShady

Moda Health received an appeal from Mr [redacted] on September 6, We will be reviewing his concerns and providing a response to him about this concern October 6, Thank you

On 10/05/I was at High Desert Eyecare purchasing new glassesMy insurance company Moda Health confirmed verbally by phone with High Desert Eyecare that I was currently covered for $towards any pair of eye glassesThis was confirmed by a Moda Employee named Sandra on 10/05/Since my insurance was still in place and confirmed I purchased new eye glassesI paid $out of pocket and Moda was to cover $of the $totalOn 02/09/High desert Eyecare received an invoice that Moda wouldn't cover the $and confirmed with Charlene over the phone with Moda that although the benefits were confirmed on 10/05/that Moda didn't have coverage in place at that time They had not received the info from my husbands previous employer to end coverage nor had they sent me information in regards to the insurance ending at this timeI emailed Moda to confirm the informationThey are refusing to cover the $they verbally confirmed was covered on 10/05/

Revdex.com Complaint ID: ***, *** ***Dear Ms***:Thank you for sharing Ms***’s concerns with Moda HealthWe reviewed Ms***’s complaint and our recordsMs*** has been enrolled on an individual medical plan with Moda Health since January 1, Effective January 1,
Ms*** enrolled on the Individual High Deductible Plan On the plan, premiums payments are due monthly and in advanceModa Health will allow a 20-day grace period after the premium due dateIf payment is not received within the grace period, the policy will end after a 10-day advance noticeCoverage will end on the last day of the coverage period (month) for which premiums were paidMembers have the option of going online to modahealth.com and logging into their myModa accountOnce logged in, members can access a variety of information regarding their plan, including the option to view and pay premium invoicesWe did not receive Ms***’s full February premium payment by the due date; therefore, a premium delinquency notice was mailed to her address on file on February 11, The notice provided the current balance due on her accountThe past-due payment was not received by the end of the grace period; therefore, her plan was terminated due to non-paymentMs*** called our customer service and explained her complaintOur medical customer service manager determined that while Ms***’s plan was terminated correctly per the plan policy, an exception would be made to reinstate the plan effective March 1, Our customer service representative called Ms*** on March 9, to advise her plan was reinstated for coverageWe hope this information has been helpful in resolving Ms***’s complaintIf we can be of further assistance, please contact our customer service department at 1-877-605-3229.Sincerely,Kristin L.Appeal Coordinator IIModa Health Quality Programs

They have a very obsolete system when it comes to processing premiums and other paymentsNo understanding and a 1% margin for errorThey would rather not take your money and deny health coverageI spoke to different customer service representatives and only one was nice and reassuring, and willing to take the time and effort to try and rectify the situationunfortunately that customer service representative was only able to do little do to the fact the accounting is a separate department and they don't take callsSo we were not able to have "eyes" on the situation and see why my payments I made were not going through

Complaint: ***I am rejecting this response because: The business violated my privacy by providing the dental provider with information about former group coverageAdditionally, Moda is not entitled to the information pertaining to current services as I no longer have an insurance/client relationship with ModaThe appropriate behavior would have been to reject the claim initially and send it back to the dental provider because it was lacking the Member ID and Group ID information required for processingI do not find the businesses response acceptable or appropriate.Sincerely,*** ***