Moda Health

Moda Health has $1,of my money and they have not refunded itI want a refund

Dear Ms***:This is in response to the complaint filed by *** ***, received at Moda Health on June 14, 2016regarding services she received at Pearl Women’s CenterMs*** indicates on June 19, shehad an annual women’s appointment with Pearl Women’s CenterShe states she was careful
tocheck with the facility and Moda Health in advance to make sure they were covered by her plan.Since all parties confirmed coverage, she proceeded with her appointmentA few weeks later Ms.*** scheduled another appointmentOnce again Pearl Women’s Center contacted Moda Healthto confirm that her services would be covered percent and she again proceeded with herprocedure as scheduledAfter a third appointment, Ms*** received a bill from Pearl Women’sCenter stating that her plan did not cover the appointments or procedure and that she isresponsible for the full amountsMs*** feels that all of the procedures she received shouldhave been fully covered if the medical center was in-networkMs*** appealed with ModaHealth and we still have refused to pay because the services were provided out-of-networkShe isrequesting the Moda Health pay the amount due to Pearl Women’s Center in the amount of$2,902.00.We thoroughly reviewed Ms***’s complaintWe received an appeal request from Ms*** onMarch 23, regarding the same issues and mentioned aboveOn April 21, we sent aresponse to Ms*** upholding our processing of her claims from the services she received atPearl Women’s CenterThe following is our determination.Ms***’s Oregon Individual Be Connected Plan effective February 1, through October 31,utilizes the Rose City Network in Multnomah, Washington, Clackamas and Yamhill counties forin-network benefitsIn-network benefits apply to services delivered by in-network providers; outof-network benefits apply to services delivered by out-of-network providersBy using an in-networkprovider, members will receive quality healthcare and will have a higher level of benefitsMembersmay choose an in-network provider by using “Find Care” on myModa or by contacting customerservice for assistanceMember ID cards will identify the applicable network.As required under the Affordable Care Act, certain services will be covered at no cost to themember when performed by an in-network providerAll FDA approved contraceptive methods andcounseling is covered when prescribed by a professional providerWomen’s contraception, whendelivered by an in-network provider and utilizing the most cost-effective option (e.g., genericinstead of brand name), will be covered with no cost sharingWhen provided by an out-of-networkprovider, covered services will be paid at percent up to the maximum plan allowance (MPA)after the out-of-network deductible is metWhen using an out-of-network provider, any amountabove the MPA is the member’s responsibilityYou can reference this information, including thedefinition of MPA on pages 3-6, 8, 15, and 24-of the Be Connected Plan member handbook(enclosed).Ms***’s claims from the services she received at Pearl Women’s Center were processedcorrectly applying towards her out-of-network benefitOur records show that Pearl Women’sCenter does participate in other Moda Health networks but not the Rose City NetworkA call fromPearl Women’s Center on June 23, was reviewed to make sure the information provided wascorrectIn review of the call we found that there were no incorrect benefits provided as ourcustomer service representative (CSR) was advised by the caller that the provider/facility was innetworkWe were not asked to confirm whether the facility was in-network or notThe CSRprovided in-network benefits correctly as it was assumed the facility was in-networkWe did notreceive any calls confirming network status of Pearl Women’s Center until after the claims wereprocessed.We appreciate Ms*** sharing her concerns with us and understand that she thought theservices provided by Pearl Women’s Center would be paid in-networkHowever, we are unable tocomply with her request to pay the in-network benefit for the services she receivedWe arerequired to administer benefits in accordance with the Be Connected PlanAt this point Ms***has exhausted her appeal rights in regards to this matterWe apologize for any inconvenience thishas caused her.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 711.Sincerely,Steven H.Appeal CoordinatorModa Health Quality Programs

I had a baby early NovAt first MODA REFUSED to add my newborn son because they stopped adding new members in WA Oct 31, Nobody told me I was not going to have coverageAfter literally spending DAYS on hold and talking with person after personI finally was able to add my sonThen they said he was added with an inactive account so he would not have coverageThen they finally made it active months laterThen they decided months later to drop coverage for me and my family for the month of DecThey said the premium was paid more than days lateI have a copy of my premium check written by my employer dated Dec1, and they say it was in the mail no later that DecI also spoke with someone named Denis who told me the premium arrived a little late but do not worry they would not cut off my insurance coverageSecondly, I am a health care provider and know a lot about codingI also spent days on the phone over denied claims that I eventually got covered

On June 19th I made an annual women’s appointment with Pearl Women’s CenterI was careful to check with them and MODA in advance of the appointment to make sure my plan was covered and accepted at this DrofficeAll parties gave me the green light and I proceeded with my appointmentsA few weeks later I scheduled another appointment to get my IUD insertedOnce again Pearl Women’s Center called into MODA to confirm I would be covered 100%Sure enough, I received a message confirming that MODA had confirmed the IUD and appointment would be covered fullyI proceeded with the procedurePer usual I went in one more time a month later to follon my IUD and make sure all was goodDuring this whole span of time, my insurance was stated to be covering everythingA few weeks after my final appointment, I received a bill from Pearl Women’s Center, saying that my plan is actually not covered, MODA will not pay it, and I am responsible for the full amountAll the procedures that I r

I have used MODA in the past for health insurance and NEVER once missed a paymentI just this year got dental insurance for my husband and I and was business days lat to make my paymentI understand that I was late because I flat out forgotHowever, this was my very first time ever forgettingI also did not get a payment reminder in the mail or via emailI feel because I have a history of being a good customer and always have paid my bill on time that this one (FIRST) time that I ever have been late they refuse to accept my payment and reinstate my policy is ridiculous! I can guarantee that if they would just take my payment and reinstate me and we continue on that I will never be late againIn fact I would be happy to set up auto payMy track record shows excellent payment history with MODA and with every other bill I have

Moda Health has been a terrible health insurance company to work with Every transaction has been miserable To top it off they continued to remove a monthly premium from my bank account after I had cancelled insurance with them In making call after call to get this reversed, they would tell me that they had no record of anything sent to them, my earlier calls, or would tell me to submit something else and then lose it I am still waiting for my refund

This is a TERRIBLE company that cares nothing about your health and wellbeing only money! There was a gross mishandling of billing between MODA and my physicians office, that was not caught for TWO YEARS, and then I get a phone call from my physician telling me to fork over the cash immediately! Three months and $later I get an ADDITIONAL bill from MODA telling me I owe EVEN MORE! No "we apologize" or "let me try to rectify that" just "send me the money" TOTAL ***! Healthcare is hard and expensive enough without the insurance provider that you pay premiums to screws you over I would dump these people if I had the choice what a disaster this place is!

Horrible accounting proceduresThis has been ongoing since January No premiums taken after EFT set upNoticed no deductions so I called ModaI was cancelled with no notice because MODA didn't take premiumsIt took many weeks to get reinstatedThen duplicate multi month premiums taken from my account which they could not acknowledgeThen when my bank removed the duplicate fraudulent withdrawal I was cancelled again back to effective January even though they had the duplicate paymentNow this week I received bills for March, April & May& they put a $credit in my account which they were no longer supposed to have access toUnbelievable! (They could not find or see the duplicate deduction they took on their end even though I faxed a copy of my bank statement)

Complaint filed by: *** ***ID# ***Case ID: ***
Dear Ms***:In her complaint to the Revdex.com, Ms*** indicates she was having difficultiesgetting Moda Health to her add her newborn son to her Washington Individual medical policyMs.*** states that we refused to add
her newborn because we stopped adding new members onWashington Individual plans effective October 31, After speaking to many customer servicerepresentatives at Moda Health, she was finally able to get her son added to her policyMs***explains that her plan was terminated eight months later because Moda Health did not receive herpremium payment for December However, her check was sent by her employer on December5, Ms*** also states that she spent more days on the phone with Moda Health over deniedclaims that she eventually got coveredShe feels that it is unfair that she has had to spend so muchtime on these issues
We thoroughly reviewed Ms***’s concernsPlease be aware that we have never received anyappeal or formal complaint regarding the issues Ms*** was having with Moda HealthIn reviewof our call records, we do show that Ms*** was told that she would not be able to add her son toher policy due to Moda Health pulling out of the Washington Health Insurance Exchange effectiveJanuary 1, Ms*** was advised that effective October 31, 2015, we were unable to add newdependents to a Washington Individual plan for this reasonThere was some confusion with theinformation our customer service department provided to Ms*** and on December 16, 2015,after review by our management team, her newborn son was added to her policy effectiveNovember 3, The addition of her son increased the premium amount due and a new billingstatement was sent to Ms*** reflecting the new premium amountWe received a payment forthe December premium on December 22, The amount received did not cover the newdependent so the plan was terminated (the premium amount due was $and we received$726.86)A refund for the amount paid was sent to Ms***’s address on file on May 16, 2016.We received calls about the processing of claims for both Ms*** and her newbornWe show thatMs*** was concerned about getting certain amounts reported to her flexible spending accountfor reimbursementWe advised that the claims had not processed and she needed to wait for herexplanation of benefitsWe also show that Ms*** called in to ask why Moda Health had not paidfor services her newborn son received on November and 10, and that she was being sent tocollectionsWe advised that we had not received any claims and offered to contact the provider on her behalfWe contacted the provider and asked that they send the claims in and we would processthem as a rushWe received the claims and they were processedExplanations of benefits wereissuedWe have not received any more phone calls from Ms*** regarding the processing of heror her family’s claims since May
We appreciate Ms*** sharing her concerns with us and sincerely apologize for the time spentand any confusion we may have caused regarding the addition of her newborn sonThe plan wasactive for her son from November to 30, and all claims from this period have beenprocessedBecause we did not receive the correct premium amount for December 2015, the planwas terminatedMs*** asked for Moda Health to refund her the premium she paid forDecember As stated above the refund was issued to her on May 16, and we haveconfirmed that it has been cashedMs*** also requested to be compensated for her time andanxietyAt this time, Moda Health is unable to comply with this request
If we can be of further assistance, please contact our office at 866-940-or TelecommunicationsRelay Service at
Sincerely,Steven H.Appeal CoordinatorModa Health Quality Programs

This health insurer is a mess! Google their recent newsIt's hanging on by a string but we stuck with them for years
Recently, I scheduled an appointment for a joint issueWe have not used the insurance for all of This appointment was in October of Come to find out our policy was cancelled without notice (which is illegal)Our premiums were always paid on time if not earlyAfter almost hours on the phone, being transferred to different people we were advised of the cancellationThis was due a "supplemental insurance" questionnaire that we never received, was not returned
It's no surprise this company has been at failure multiple times over the past yearsHey Moda, why not hang on to the customers that pay on time and never use your service and not pay millions upon millions of dollars for stadium naming rights
Bottom line, I would advise finding another provider

My wife had a complex pelvic surgery with a surgeon and hospital in Seattle, Washington on 07/20/Moda has processed the hospital charges at an out-of-network rate with a higher co-insurance cost and possibility of being balance billed by the hospital where this procedure was performed even though our initial consult with the surgeon who performed the surgery as well as the surgeon's fees themselves were processed at an in-network ratePer my conversation with the Moda customer service rep, the in-network processing of the charges "were a mistake," but because of Moda's mistake, we chose to go forward with having this surgery done at a hospital that we find out after-the-fact as being out of networkIf these charges were processed correctly in the first place (at an out-of-network rate), my wife and I would have chosen to have the surgery elsewhere in the first place

Dear Revdex.com, I have held a health insurance plan through MODA since Jan At the beginning of this year, they required that all customers move from paying by credit card to paying through direct bank depositI did this, however, they did not immediately notify of the rate increase and I could not find the information on their website or in the literature they sentI directed my bank to send $/ month, which was the rateAs it turns out, the rate is $/ monthFor an underpayment of $MODA has permanently cancelled my health insurance and says it will not reinstate regardless of whether I pay the $What this means is that for less than $20, which I am happy to pay immediately, this company is putting me and my family at risk of financial catastrophe and leaving me without medical coverageIf this is legal, it is certainly not ethicalI am not sure why it is in their financial interest to terminate a customer in good standing unless it has something to do

Both my son and I submitted reimbursement claims for $each for eye ware purchased at Costco on 12/27/ I have another medical claim (also prepaid) dated 1/5/which was submitted and received by MODA I have called approximately times since January to follow up on these claims which have been logged onto my account and are viewable through the MODA website Multiple times, I have been told that the checks will be cut "on Friday..." I have asked for Escalation, Supervisors, and Management to intervene to have these funds reimbursed On 3/2/17, I was "assured" by Robert that submitting these claims to his Supervisor for escalation would result in their being paid "within 7-business days" They were not I called again on 3/16/and spoke to Leslie She told me she would get them released and call me back She did not I called again the morning of 3/17/and spoke to Marissa and Greg, her Supervisor Greg took my number and assured me that he would release the f

We received an Oregon Insurance Division (OID) complaint and it is due 2/23/2016.  We are in the process of investigating this concern along with the OID complaint and will respond by 2/23/2016.

Revdex.com Complaint ID: [redacted] Dear Ms. [redacted]: Thank you for sharing Mr. [redacted] concerns with Moda Health. We reviewed Mr. [redacted] complaint and our records. Mr. [redacted] has been enrolled on an individual medical plan with Moda Health since January 1, 2015. Effective January 1,...

2016 Mr. [redacted] enrolled on the Individual Be Protected Plan. On the 2016 plan, premiums payments are due monthly and in advance. Moda Health will allow a 20-day grace period after the premium due date. If payment is not received within the grace period, the policy will end after a 10-day advance notice. Coverage will end on the last day of the coverage period (month) for which premiums were paid. Members have the option of going online to modahealth.com and logging into their myModa account. Once logged in, members can access a variety of information regarding their plan, including the option to view and pay premium invoices. Mr. [redacted] automatic premium payment was returned to him due to non-sufficient funds. We did not receive Mr. [redacted] April premium payment by the due date; therefore, a premium delinquency notice was mailed to his address on file on April 12, 2016. The notice provided the current balance due on his account with a due date of April 20, 2016. The past-due payment was not received by the end of the grace period; therefore, his plan was terminated due to non-payment. Mr. [redacted] called the Oregon Department of Consumer and Business Services and explained his complaint. Our medical customer service manager was contacted and determined that while Mr. [redacted] plan was terminated correctly per the plan policy, an exception would be made to reinstate the plan with no break in coverage. Mr. [redacted] had changed his address but had not notified Moda Health, which caused a delay in receipt of his delinquency notice. Our customer service representative called Mr. [redacted] and on March 9, 2016 his plan was reinstated for coverage. We hope this information has been helpful in resolving Mr. [redacted] complaint. If we can be of further assistance, please contact our customer service department at 1-877-605-3229. Sincerely, Kristin L. Appeal Coordinator II Moda Health Quality Programs

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.

Member: [redacted] ID#: [redacted] Subscriber: [redacted] Group#: [redacted] Case ID #: [redacted] Dear Ms. [redacted]: This is in response to your letter dated May 17, 2016 in which you informed us of Mr. [redacted] complaint regarding a refund on his individual policy. We apologize for the delay in our...

response and for Mr. [redacted] inconvenience in this matter. Mr. [redacted] stated in his complaint that Moda Health has $1,824.00 of his premium dollars that need to be refunded to him. Mr. [redacted] was terminated on March 31, 2016 for non-payment after he switched banks and did not set up bill pay for Moda Health to draft the premium. The payments for April and May were received after the policy was already terminated. He called and was told that he would receive a refund for the $1,824.00 on April 13, 2016 in 2-4 weeks. He still had not received a refund and called again to Moda Health on May 17, 2016. He was told that if he gave Moda Health his checking account information that a direct deposit would be made into the account from which it was removed. That was over a week ago and the member has still no refund. We reviewed Mr. [redacted] complaint and verified on May 19, 2016 the premium refund request in process for the amount of $1,824.00 and will be deposited into Mr. [redacted] account via Automated Clearing House (ACH) and will be completed in one week. This issue has been resolved with Moda Health, and we would like to apologize to Mr. [redacted] for the delay in his premium refund. If we can be of additional assistance, please contact our office at, locally 503-243-3962 or, nationally 1-877-605-3229, and Telecommunications Relay Service at 711.

In order to respond to this concern, we need a member identification number or claim number.  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 me. The issue is when contacting Moda Health they were giving me a different timeline on the return of the funds. The first time it was not established this would be the process, the second time it was noted it would take 2 to 4 weeks to process the information, and the last time confirmed this information. If they had noted this during the first conversation of how long the potential turnaround time was for processing it would not have been an issue. The issue is I was given a different story every time I contacted them. If their customer service reps can give the same information every time that would be great. Sincerely, [redacted]

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