Moda Health

My wife [*** ***(***)] are both teachers in the *** *** *** ***Each one of us was a primary card holder with the other as a spouse (dependant)We chose to be double covered 2015-year because I wear contacts and she needed to order glasses this yearMarty at Estacada Vision in Estacada, OR, spoke with SEVERAL representatives at Moda Health on many different occasions to find out how to bill primary and secondary insurance so we could be fully coveredEach time she spoke with a rep from Moda, they gave conflicting answers on how to submit our insurance so we would both be fully coveredOne rep would say we needed to "Coordinate Benefits" and the next would say to "Un-coordinate Benefits." Each time, Marty at Estacada Vision would submit the claim and then it would not be covered Marty talked to different people times and also submitted claims many times She called me one day and said she has spent hours attempting to figure it out and kept getting

Complaint: ***I am rejecting this response because: In their reply they say that if I was receiving a tax credit deal that I should have been allowed a month grace period! I was not given that grace period and yes I did qualify for a tax credit and was using it I am still ready to make march payment as I was on March 29th when I realized on my own I had forgotten to pay I see that they did send me a notice however the notice never reached my PO Box I understand that it not reaching my PO Box is not their problem as they clearly did send it USPS has been known to lose mail However I am asking one more time to be allowed to pay my March bill and My April Bill and be reinstated without lapse in coverage because I was in fact receiving the tax credited deal for my plan.Sincerely,*** ***

Our response is attached for your review. Thank you
Dear Ms***: This is in response to the complaint received at Delta Dental of Alaska on January 4, 2017, regarding *** ***Ms***’s complaint states she called to confirm her dental work would be covered before she had
services renderedShe was told by a Delta Dental of Alaska representative that the dental work was covered and she proceeded with her appointmentMs*** was then contacted by her dental office stating no payment was received for her dental servicesWhen she called Delta Dental of Oregon again she was informed it would be covered and then informed by a different representative that it would not be coveredMs*** states the amount in the complaint is $and she would like the claim paid and a full refund of her premiumsWe thoroughly reviewed Ms***’s complaintMs*** had services on September 26, with Mark J***, DDSMs*** had periodontal scaling and root planning performed on this dateOn Ms***’s Delta Dental of Alaska, Delta Dental Preferred Provider Organization (PPO) Plan, covered dental services are outlined in three "classes" that start with preventive care and advance into specialized dental proceduresLimitations may apply to these servicesClass III restorative services include periodontic services such as periodontal scaling and root planningClass II services are subject to a 6-month waiting period and Class III services are subject to a 12-month waiting periodHowever, the waiting period will be waived if the member provides evidence of continuous months of prior dental coverageTo qualify, the previous plan must have provided coverage for standard dental services as determined by Delta DentalEnclosed are pages 7, and of Ms***’s Delta Dental PPO Plan with her benefit informationMs***’s was effective on the plan starting March 1, through December 31, Ms, *** had the periodontal scaling and root plaining on September 26, 2016; therefore, her claim denied correctly for services received within the waiting period limitationIn regards to Ms***’s correspondence with Delta Dental of Alaska, here is a list of Ms***’s correspondence: • March 7, 2016- Ms*** emails Delta Dental of Alaska to obtain benefits for cleanings and explains that she has to wait to have fillings doneThe Delta Dental of Alaska representative responded to Ms*** stating “prophylaxis services” (cleanings) and other preventative services are covered right away, Restorative Services (Fillings) will be covered as of September 1, and all other covered services will be covered as of 03/01/• DrJ*** office verified MS***’s dental benefits online on August 29, Ms***’s perio services showed zero percent coverageThis information was given to the member by the provider explaining that her services would not be coveredThis information was verified with the provider’s office by Delta Dental of Alaska on January 4, • Ms*** called on November 10, to have the claim adjustedThe claim was routed to our dental claims department and on December 13, 2016; the customer service representative was informed it was denied for waiting period and no adjustment was neededThe representative contacted Ms*** to explain the denial• Ms*** called on December 14, and questioned the claim and why the claim was not adjusted and she stated that she was mis-quoted prior to having services renderedThe call was reviewed and a call placed to the dentist officeIt was confirmed the correspondence described above (March 7, 2016) was not a mis-quote and her provider also verified she was informed that the services were not covered prior to services being renderedWe appreciate you sharing Ms***’s concerns with us and understand that she would like Delta Dental of Alaska to process the claim and refund her premiumsAfter reviewing Ms***’s plan, correspondence and benefits; the claim was denied correctly and there is no error on Delta Dental of Alaska’s behalfIn addition, Ms*** or her authorized representative may contact the Employee Benefits Security Administration at 866-444-for questions about your rights or for assistanceIf we can be of further assistance, please contact our office at 888-374-or Telecommunications Relay Service at Sincerely, Lowanna NAppeal Coordinator II Quality Programs Enclosures
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I have a high tolerance for shortcomings in the abusive health care industry, but MODA's most recent shirking of responsibility has crossed the lineI will be making copies of my dental denial and passing them out at our next employee benefit meeting to advise everyone to switch from MODA to KaiserThis little bit of activism will help me sleep at night

Complaint: ***I am rejecting this response because:
Moda Health denied my appeal
(made a final internal adverse benefit determination) via formal letter on November 24, (see attached appeal response dated November 24, 2015) I contend that my visit to Dr*** on October 5, 2015, for $198.40, should be covered under the $“first three medical visits” co-pay because I was told that this visit would be covered in my telephone call to a Moda Customer Service Representative under the “first three medical visits $co-pay (deductible waived).” I was told this PRIOR to making my appointment with Dr***, and I only made this appointment with Dr*** because I was told by the Moda Customer Service Representative that it would be covered under the $co-pay If I had received information from Moda’s Customer Service Representative that Dr*** was NOT covered, then I would have gone to a different non-specialist in-network provider who WAS covered under this $co-pay Moda contends that this visit was to a specialist, and that it should be applied to my deductible, which is how they processed it (see attached EOB), resulting in that I had to pay the entire charge out of pocket because my deductible wasn‘t met In Moda’s appeal denial letter Page 2, they stated “However, our representative would not be aware of how your visit would be billed, and we process claims as billed by your provider.” Then why, I am wondering, if the representative would not be aware….then why did she specifically tell me how the visit would be charged, specifically, that it would be “Mm hmm [yes]…the first visits correct? So, you have only used one…so…yes” in response to my question regarding an appointment with Dr ***, “If I just made an appointment, it would be the $35.00?” (See page of the attached transcript of that phone call.)
I questioned, too, the accuracy of the transcript of the October 5, 2015, phone call to the Moda Health Customer Service Representative (see attached) I believe I questioned the Moda CSR (Customer Service Rep) a few additional times regarding that the visit to Dr*** would be covered under the $co-pay, which was left off the transcript So, I requested that I get an audio version of the phone call I made to the Moda Customer Service Rep on October 5, 2015, because I thought the transcript of the phone call omitted some important dialogue See C***, the Moda Health Privacy Specialist, told me that they would NOT provide me an audio recording, and told me, “Please be re-assured that our medical customer service team transcribed the requested phone call word for word.” When I insisted that I specifically remembered some of the dialog that did NOT appear on the transcript, she answered, “I listened to the phone call and on page three of the phone call transcript, after the customer service representative provided you the name of *** ***, she did spell out “***” for you--this was left out on the call transcript.” So, she admitted that some information was left off the transcript and that, indeed, it was not transcribed “word for word.” I do not know what else was omitted, because I could not obtain an audio version The Privacy Specialist said that if I wanted to hear the audio, I would have to travel to their office in Portland However, that would cause hardship for me and is impossible to do, since I am currently living in Arizona on a temporary basis
Sincerely,*** ***

This is in response to the complaint dated January 19, in which you informed us of Mr.*** compliant regarding the termination of his wife and children’s individual policyMr.*** who filed the complaint is not on the plan
Mr***’s complaint states he cancelled his
wife and children’s health insurance policythrough Moda Health via the Moda Health website for the year as they elected to go with adifferent companyOn January 7, 2016, Moda Health deducted $for the January 1, 2016plan which had not been cancelledModa Health withdrew the money without authorization andModa Health is stating that they will not be refunding the $backThe website confirmed thecancellation, however no email was receivedMr*** called Moda Health on January 8,and he was assured that a refund would be issued and it would be issued no later thanJanuary 13, Moda Health called Mr*** on January 18, and informed Mr.*** that he would not be receiving a refund for the $Mr*** is lookingto cancel the policy and receive a refund
Upon receiving Mr***’s complaint our billing and eligibility department terminated thefamily’s policy effective December 31, A refund is the amount of $will be refunded viaAutomated Clearing House (ACH)Moda Health out reached to Mr*** on January 22,and left a message with this informationThis issue has been resolved with Moda Health.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

Thank you for sharing Ms***'s concerns with Moda HealthWe reviewed Ms***'s complaint and our recordsMs*** is on the Klamath Child and Family Treatment Center Preferred Provider Organization (PPO) medical planFor members age or over, the plan pays benefits for visions
examinations and corrective lenses and frames up to a $annual maximum for all combined servicesPayment is based on the contracted fee for in-network providers and billed charges for out-of-network providersWhen a member is billed by a professional provider directly, he or she should send a copy of the bell to Moda Health with a completed claim formModa Health will report its action on a claim by providing the member a document called an Explanation of Benefits (EOB).Ms*** stated that she submitted claims for vision services for both her son and herselfThe claims were submitted to Moda Health for reimbursement and as of March 17, 2017, the date she submitted this complaint, the claims were still unpaidMs*** had made multiple phone calls to Moda Health customer service requesting expedited claim processing without resolutionShe is asking for her claims to be paid immediately. We received Ms***'s claims on January 3, for visions services she and her son received on December 27, In the comlpaint, she also mentions that she had another prepaid medical claim dated January 5, t is unclear what claim she is referring to and we are unable to comment on this statementWe also show that Ms*** did make multiple phone calls to our customer serviceDuring each phone call, she was given accurate information from our customer service representatives based upon the information listed in the claim processing systemAt this time, this matter has been resolvedOn March 23, 2017, Ms***'s claims were released for payment and a check in the amount of $was mailed to her on March 24, Ms*** was also sent an EOB on March 24, 2017.We appreciate Ms*** sharing her concerns with us and apologize for the delay in the claim paymentModa Health takes these complaints very seriously and we will use the documentation provided as feedback to our customer service team.We 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

I received an EOB form from Moda on 09/28/2016, despite the fact that I do not currently have a plan with ModaI called Moda's dental customer service on 09/28/to notify them of the error, but in order to discuss the problem I had to provide an extensive amount of personally identifiable information such as DOB, Last of SSN, etcI was also required to provide a current phone number which Moda did not already have and has no valid reason to obtain or recordI was told by a customer service representative that given the information I provided, it appeared the claim on the EOB had been sent to Moda in error by the dental providerI pointed out that the EOB form has a Group and Group ID # for a former employer, however, and the dental provider did not have that information and therefore could not have provided it with the claimThe customer service rep, who I will refer to as M, said that a Moda employee matched the former employer information from my account to this claim is j

Member: ***
*** ID#: ***Subscriber: *** *** Group#: ***Case ID # ***Dear Ms***:This is in response to the complaint filed by Ms***, received at Moda Health on January 22, Ms*** is stating requesting a refund of premiumsMs*** stated in her complaint she decided to go with another insurance company for her medical coverageShe received a letter on December 10, stating that the medical plan would end on January 1, When she went online to pay her dental premium there was nowhere to pay the premiumShe contacted Moda Health and was informed that her application was still under review and due to her concerns about getting the premium paid was suggested to set up auto withdrawal for the $premium a monthOn January 19, she noticed that a payment in the amount of $was pending in her bank account, she contacted Moda Health and was informed it could take three weeks to be refunded. Ms*** also encountered overdraft fees for this errorMs*** is requesting her refund sooner than three weeks and her overdraft fees returnedWe reviewed Ms*** complaint and $was drafted from Ms*** account, $for her medical premium and $for her dentalUpon review, Ms*** medical premium payment in the amount of $was deposited back into Ms*** account via Automated Clearing House (ACH) on January 26, We contacted Ms*** on January 25, and informed her that the amount was being refunded and informed Ms*** that proof of the overdraft fees were needed in order to review for a refundMs*** stated that she only incurred one overdraft fee of $Moda Health received the proof submitted by Ms*** for the overdraft fee and this amount will be refunded to the member as well This issue has been resolved with Moda HealthIf 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

Attached is our response, the claim was processed correctly
***Documents redacted by Revdex.com***

Called to confirm my dental work wold be covered before serviceI was told by modal that it was and proceeded with my appointmentWas contacted by my dental office saying no payment had been received so I called modal and spoke with Heather and was told it should be coveredReceived a phone call today stating they will not cover any bill and said there it's nothing I can dueNot only am I upset but I feel as if fraud is being committed

I spoke with a MODA representative during the lunch hour to request some information regarding benefit booklets The gal refused to offer assistance and she informed me that Benefit Handbooks are protected under HIPAA law I informed her that they aren't protected under HIPAA Had I asked for specific medical records...then yes that is a violation of HIPAA but I didn't
She told me that she was not going to risk her job to help assist me I asked her to please transfer me to a supervisor and she again told me that she would refuse to do so because a supervisor would also not assist me I told her that she was not at liberty to decide what her supervisors may or may not assist me with
She said she would under no circumstances transfer me and would disconnect the call I told her that was fine and that I would take the necessary step to report her and MODA to the Revdex.com for refusing to assist me with insurance information
I have never been more disrespected by an insurance agent than I was today by MODA Ironic thing is...I used to covered by and then carried my own MODA insurance for over years Not once did I ever have issues or a single complaint I no longer carry MODA insurance because of employer provided coverage and I have to say I have never been more disgusted with service
MODA rep was so concerned with her job that this type of behavior and refusal of service should put her job and future with MODA or any other insurance based company at HIGH risk

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me
Sincerely,
*** ***

Moda Health has been terrible to work with throughout my experiences with themIt has taken months and many phone calls to attempt to get a refund for a charge which was their mistakeThey now say the refund will show up in the next few days (againthis is a line I have heard several times from them)While I was actually using their services, they were difficult to contact and difficult to work withI definitely would not recommend using their services

Moda Health*** *** has failed to serve my family in a reasonable manner for the past eight monthsI have logged hours on the phone with the customer service department of MODA and while the associates are willing to help they have not been able to undo the various bungles this company has made with regard to my family's dental insurance - It all started with a mistake on the part of MODA - my husband phoned them to inquire about their dental insuranceMODA against policy as I was later told added my husband to the insurance policy that I hold with my two childrenThis was not what he had requested - he had asked to be put on a different more comprehensive kind of planBut MODA unlawfully added him to my insurance policy without consulting me the primary holder of the dental insurance policy or requiring an application from himFor months we unwittingly paid a premium for the four of us for the wrong types of accounts.My husband had a dental procedure performed at the beginnin

I returned to Moda as my health insurance through the exchange- they added a policy I didn't pick- close to 3hrs on hold w the exchange and then Moda because it was a Moda issue even though a CSR directed me to the exchangeThat issue was apparently resolved after the 3rd callI went to pay Moda- they only take EFT/ checks as paymentThey now have my bank account info (yikes!), they charged me $under ODS which is an old subsidiary of theirs- not my premiumI spent 4+ calls in an attempt to get the right amount taken and the $refundedThey gladly took more $ in a hurry, but took their sweet time refunding the $I ask for an account credit for my wasted time, but they claim they don't do that( + the bank and the exchange) phones calls is too manyIt should be ONE and doneNot a happy customers w minimal other choicesStill waiting for my $Won't be recommending Moda to anybody any time soon

Awful in every way imaginable Got an email asking me to sign up for the new health plan and cancel the plan I cancelled the plan to take effect on the last day of and signed up for a new plan filled out all the informationwhen January came and I didn't get billed for that month I called them and they told me they received my application and that they were "behind" and that they would take care of it Fast forward to February 17th when I get a call telling me I don't have any insurance and that I never signed up for the plan When I referenced the conversation I had in January they just ignored me and repeated they didn't receive my enrollment Now my insurance has lapsed and I can't get it since I am past the enrollment date I will be also be fined 2.5% of my yearly income by the federal government This is going to be close to $USD in fines

This complaint is regarding the processing of Mr*** claim for contact lenses he purchased on July 25, from Candace ** H***, ODMr*** indicates that he had dual vision coverage with his spouse and chose to do so, so he could purchase contacts in the 2015/plan yearHe states
that his vision provider’s office spoke with several customer service representatives (CSRs) at Moda Health on many different occasions to find out how to bill primary and secondary insurance so he could be fully coveredThe provider received conflicting answers regarding the coordination of benefits from our CSRsDue to the misinformation provided by Moda Health, the provider submitted the claim which would then deny coverageThis issue has not been resolved and Mr*** is requesting that Moda Health pay him or his provider the amount needed to pay for his contact lenses We reviewed Mr*** concernsOur records show that we received phone calls from both Mr*** and his vision provider’s office in July through December regarding Mr*** benefits and how to either coordinate or uncoordinated his benefitsThere seemed to be much confusion all parties on what needed to be completed in order for Mr*** to be able to maximize his benefits for his contact lenses and vision exam that he had already received previous to his purchaseMr*** originally requested his benefits be coordinated between his primary and secondary vision plansThis was updated in our system effective July 21, This information did not change until Mr*** requested that the coordination of the vision benefits only be uncoordinated effective September 30, This means that Mr*** had coverage available on both vision plans on the date he purchased his contact lenses We reached out to our claims department to review the claimWe originally only processed the claim on his primary coverage which only paid $(the remaining amount of benefits for the primary plan)We did receive another claim submission with the correct ID number, but the claim was not processed on the secondary coverageWe apologize that this did not get completed and seemed to be overlookedIn lieu of this complaint, our claims department is now processing the claim to allow benefits on the secondary vision plan We appreciate Mr*** sharing his concerns with us and sincerely apologize for the confusion and frustration this claim issue causedIt is obvious that clear instructions were not provided on how to submit the claim for the contact lensesThe claim is currently being processed and payment will be made and an explanation of benefits will be available soon If we can be of further assistance, please contact our office at 866-940-or Telecommunications Relay Service at Sincerely, Steven HAppeal Coordinator Moda Health Quality Programs

This company must have undercut our former insurance plan We hav eless benefits than we had before and it is cumbersome and difficult to get your money back

Thank you for bringing this issue to our attention. We received an appeal from Mr*** on July 15, regarding this same issue. On July 30, a letter was sent to him explaining that due to the circumstance his policy could be reinstated. He owes $to bring his account
current. The letter sent to him explained to him the process of how to get the payment to Moda Health. The letter is attached for your review. Thank you
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