ComplaintsforModa Health

• Initial Complaint

  07/19/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Moda health is refusing to pay for a medical procedure done and covered under womens health in my insurance handbook. I have called them over 100 times to get things they claimed they needed to be able to pay for this. I have supplied them with prior authorization numbers, claim codes, billing numbers, doctors notes, etc. I am calling them again in July of 2024 because the bill is now outstanding and they claim that this bill no longer exists. It still very much does exist with Good Samaritan billing and Im going to be taken to claims for it. They are also refusing to pay for a well child visit for my daughter who was 8 days old at the time. **** is being fraudulent by deleting the claim that I have requested them to pay for. I have called them today 7/19/2024 at 1:43 pm and they still claimed to not have it. I produced the claim number and magically it appeared on their end. They still wont pay for it despite it being covered under womens health. This company has cost me irreplaceable time, mental health, and my own money for this things that we pay our insurance to pay for. Mentally I am sick with the amount of effort I have put into doing these peoples jobs. I am seeking compensation for my efforts, and the stress this has caused my family and I. ************* should be investigated for insurance fraud. My primary care office can attest to how many things I have done for moda, and that they have sent the required documents for moda. My provider is *** ****** in ******, Oregon.

  Business response

  07/22/2024

  We read through this concern.  The complainant does not provide the names of provider, dates of service or any specific claim information for Moda Health to identify what claims are not being processed.  Can you please reach out to the complainant to have them provide more information to Moda Health.  Thank you. 

  Customer response

  07/22/2024

   
  Complaint: 22015996
  
  I am rejecting this response because: they already have all of this information on file. Or every customer ********************** representative has lied to me. 
  
  Sincerely,
  
  *************************

  Business response

  07/29/2024

  Thank you.

  Customer response

  07/29/2024

   
  Complaint: 22015996
  
  I am rejecting this response because:

  they still have not fixed the issues. I owe $900 that should be mostly covered by insurance. 
  
  Sincerely,
  
  *************************

• Initial Complaint

  03/28/2024

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  I signed up for Moda Health Insurance prior to the 2024 year starting. I had all payments for health insurance premium on autopay from the year prior. I checked online and verified this and also made sure my dental insurance was an auto-pay. I found out in early March that my health insurance was somehow not in effect, so I contacted Moda. My autopay was not going through, and so I offered to pay all back pay and make sure my autopay was correct. Instead, a week later they called to tell me they were dropping my coverage after sending two letters informing me that my payments were delinquent. There was no phone call or email prior to this point, and I did not see the letters they mailed. Despite my plea of wanting to cover the missed payments and resume coverage, they cut me, leaving me unable to get health insurance otherwise since I'm no longer eligible. I'm no longer eligible BECAUSE I signed up for Moda on time. The year prior there was an issue with autopay and Moda allowed me to backpay and rectify the situation and keep my health insurance.

  Business response

  04/04/2024

  Thank you.

• Initial Complaint

  03/18/2024

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Answered

  More info

  MODA Insurance had me set up on EFT payments for my monthly premium. They correctly did an EFT for ******* of 2024, then somehow on their end did not continue to do EFT for my premium from my bank account. And yes there were funds available, they just didnt perform the transaction. They cancelled my insurance policy and I now have no coverage until a new policy starts. This also leaves me with pending medical claims that they approved through a pre authorization.

  Business response

  03/26/2024

  Hello- We also received an insurance division complaint filed by this member.  We are investigating the matter and will have a response by 4/9/2024.  Thank you.

  Business response

  04/02/2024

  This is in response to the complaint received at Moda Health on March 18, ********************************** 
  ********* premium and eligibility for the 2024 plan year. 
  

  ******************** became active on an Oregon Individual Plan, purchased directly through the Federally Facilitated 
  Marketplace (***) effective January 1, 2021 with no lapse in coverage. Per the **** she did not qualify for an 
  Advanced Premium Tax Credit (APTC). Effective January 1, 2024, ******************** is on the Moda Health Bronze Plan. 
  

  In the complaint, ******************** explains that Moda Health had her set up on electronic funds transfer (EFT) for 
  her monthly payments. Moda Health correctly withdrew funds for the January 2024 premium but did not continue 
  to withdrawal her premium payments when funds were available in her bank account. She states that Moda 
  Health terminated her policy and she no longer has coverage until a new policy starts. This leaves her with pending 
  medical claims that have been approved through prior authorization. Ms. ********* desired settlement is to 
  receive billing adjustments. 
  

  On the Moda Health Bronze Exclusive ********************* (EPO) Plan, eligibility and enrollment are 
  administered by the Marketplace. Contact the Marketplace for information. You must tell Moda Health and the 
  Marketplace whenever your address changes. The amount of premium you owe is shown on your premium notice.
  You may contact the Marketplace about premium tax credits. We must receive your premium payments every 
  month to keep your coverage active. You can pay by check, cashiers check, money order or prepaid debit card 

  with a billing statement, or by electronic fund transfer (EFT). Electronic billing (eBill) is also available. This lets you 
  pay your monthly premium on your Member Dashboard using your bank account. 
  

  These circumstances will cause your coverage to end: 
  

  a. The subscriber is no longer eligible for coverage through the Marketplace 
  b. The subscriber moves outside the Plans service area 
  c. The dependent is no longer eligible as a dependent 
  d. Premium is not paid 
  e. Subscriber ends coverage after the required advance notice or changes plans during an open enrollment 
  or special enrollment period 
  f. Rescission for fraud or intentional material misrepresentation
  g. We end this health benefit plan option
  h. We are decertified to offer plans through the Marketplace
  

  Coverage ends on the last day of the month through which premiums are paid unless otherwise required by law. 
  If your coverage was paid with financial aid in the form of tax credits through the Marketplace, coverage ends on 
  the last day of the first month of the ***** period.
  

  This information can be found in the enclosed Moda Health Bronze EPO Plan handbook pages 56-58.
  

  We thoroughly reviewed the complaint. Please see the below timeline of events:
  

  1. October 6, 2023: Ms. ********* 2024 eligibility was received by Moda Health from the ***.
  2. November 14, 2023: Moda Health received the ***s request to terminate Ms. ********* policy effective 
  January 31, 2024. 
  3. November 16, 2023: The *** sent Moda Health a plan change making Ms. ********* policy active 
  effective January 1, 2024 with no change to the termination date (effective January 1, 2024). 
  4. November 16, 2023: Moda Health sent ******************** a termination letter (enclosed). 
  5. December 6, 2023: ******************** called the Moda Health Customer ********************** Department and was advised 
  she is set up on electronic funds transfer (EFT).
  6. December 7, 2023: Moda Health sent ******************** a final premium notice (enclosed). 
  7. December 20, 2023: Moda Health sent ******************** a plan continuation letter (enclosed) reflecting an 
  effective date of January 1, 2023.
  8. January 10, 2024: Moda Health sent ******************** a plan continuation letter (enclosed) reflecting an 
  effective date of January 1, 2024. 
  9. March 18, 2024: ******************** contacted the Moda Health Customer ********************** Department to discuss the 
  termination of the plan. The Moda Health agent researched and called ******************** back the same day 
  to advise her that termination came directly from the ***. 
  10. March 18, 2024: Moda Health received the Better Business Bureau (BBB) complaint that Ms. *************************************************** was set up on EFT and Moda Health successfully received her premium payments through January 
  31, 2024. Moda Health was advised by the *** to terminate her policy effective January 31, 2024. For this reason, 
  the EFT was also terminated, and premium payments were no longer withdrawn.
  

  We understand that Ms. ********* desired settlement is to receive billing adjustments. Moda Health has 
  processed the claims, with service dates January 1, 2024 January 31, 2024, in accordance with the plan. Moda 
  Health has not received and/or processed any claims for ******************** with service dates February 1, 2024
  forward. If ******************** would like to continue coverage, she will need to discuss with the *** as directed during 
  the call she made to Moda Health on March 18, 2024. 
  

  We appreciate the time ******************** took to share her concerns with us, and we understand the situation as it 
  has been explained. However, we are unable to comply with her request for benefits. We are required to 
  administer benefits in accordance with the *** and the Moda Health Bronze EPO Plan. If she has follow-up 
  questions, we welcome her to contact our Customer ********************** Department. They would be happy to assist her.
  

  Questions? Please call our Moda Health Medical Customer ********************** Line at ************ or Pharmacy Customer 
  ********************** Line at ************. TTY users, dial 711.
  

  Sincerely,
  
  Kacee 
  Appeal Coordinator II
  Moda Health Appeals Department
  

  
  

• Initial Complaint

  02/05/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I was enrolled in their ebill autopay for $70 a month. The plan was never renewed. They renewed it and took $3.715. 86 out of my checking account without my authorization.

  Business response

  02/05/2024

  Hello,

  We are not able to identify this person as a Moda Health member.  Please provide a member identification number so that we can look further into this concern.  Thank you.
  

  *********************

  Supervisor, Member Appeals for Moda Health

• Initial Complaint

  01/29/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I signed up for insurance with Moda through the ***** exchange to start 12/1/2023. Later in December I learned there was an issue with my premium payment, so I called and gave them my bank info - at that time I was assured their billing department would pull my payments from my bank and that I would be enrolled in autopay. In January I realized I still didn't see money withdrawn from Moda and called again - Moda Health had canceled my insurance due to lack of payment and hadn't sent me a single notification about it. They told me I was in a grace ****** so if I paid my ****************** premiums and enrolled in autopay I could get back on my insurance. I agreed and once again gave them my banking information. That was four business days ago and every time I call, the customer ********************** rep just tells me it's "with their billing department" and that it should be done soon. Meanwhile I have no health insurance and am at-risk of losing insurance for the entire year since we are no longer in open enrollment. I would like someone at Moda to just take the money from my bank account for the premiums, reinstate my insurance, and put me on autopay as I requested over a month ago.

  Business response

  02/06/2024

  Thank you.

• Initial Complaint

  12/13/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Over the past three years i have been dealing with a misdiagnosis of GERD when I could still afford health insurance. I changed my diet, lost weight, and shifted all of my eating schedules around a GERD diagnosis. Only recently had I been able to afford health insurance, at least I'd thought so. Upon going to healthcare.gov to search for easily laid out information on how to select health insurance I went down the rabbit hole that is the intentionally confusing and awfully marketed plans meant to confuse and mislead consumers. The plan I selected ended up being under MODA health insurance. Since then, I have spent thousands and thousands of dollars getting multiple tests, seeing multiple different types of doctors (ENT, FP, GI) all to be diagnosed with Achalasia II and recommended for a POEM's procedure. This was about 4 months ago. MODA was forcing me to go out of state (where they wouldn't cover basically any of the cost of travel, housing etc.) and would not approve an out of network doctor in Alaska. They then denied me setting a date for THIS year by denying guided anesthesia which is incredibly normal for a surgery just got it to get pushed back to around the date i had it scheduled for, so I'd be FORCED to pay them more money and have the surgery be for NEXT year. they have 3 different types of deductibles that aren't mentioned when signing up on the healthcare.gov website without intensive digging. this is supposed to be for those who can't afford private insurance and need the aid, clearly, it's not. it has put me in debt just seeing the 4 different doctors and only having 3 tests that have somehow added up to almost $7500 dollars and that's just the tests! not any of the extra costs like taking my *** deductible and then almost my *** out of pocket. I have nothing to show except tests results, debt and now i need to find a way to afford insurance that won't try to steal my money. this isn't right. I am willing to press charges. This is health extorsion.

  Business response

  12/15/2023

  We are sorry to hear about ********************** concerns. We are unsure, however, what it is exactly that he is wanting from Moda Health.  If he has a quality of care complaint about the medical care he has been provided and received by specific provider's, he can write to Moda Health and give details about his experiences.  We would need medical records from the clinicians that he has concerns about to review the complaint. ****************** also speaks about the thousands of dollars he has paid for services.  We would encourage him to log in to MyModa and create an account.  He can access his plan benefits here too so that he can understand the plan requirements, benefits and cost share for services in and out of network. We have no prior authorization on file for the **** procedure that ****************** speaks about and no requests for an in network benefit exception that has been denied.  The only denial on file is for a CT scan for his neck.  If ****************** disagrees with this denial, he may appeal.  In the denial letter he was provided appeal rights.  As for the Federally Facilitated Marketplace (***) not providing all deductible amounts for the medical plan that ****************** selected, Moda Health has no control over what the *** posted about our plans. We are sorry for ********************** frustrations. Please have him reach out to customer ********************** at ************ if he needs additional assistance.  Thank you, **********, Moda Health

• Initial Complaint

  08/15/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  While applying for health insurance on, June 30th 2023, Moda employees informed me that I would not be eligible for insurance for July. That it was too quick of a turn around time but that I should have insurance by August. I still had not heard anything from MODA by August. On August 4th I received a call about my coverage stating that they received the paperwork but that they needed more information as to why my insurance was canceled. I provided the information and was told that I had insurance for August. I then received a bill for July. I called and spoke with ********************* who informed me that they had backdated my insurance and that I was covered for July even though I was told that I was not covered for July. Even assured me I would not be charged for July since they told me that I was not covered. I was then charged for July anyways. After speaking with a representative today I was told that she would put in a request to refund my money but that she couldnt guarantee I would be refunded because I have no proof.

  Business response

  08/29/2023

  Thank you.

  Customer response

  08/30/2023

  To whom it may concern,
  
  There has yet to be a resolution regarding case number ********. I received a voicemail on August 17th that I would be refunded for July 2023. I have still not been refunded. 
  
  Thank you, 
  **************************;

  Business response

  09/05/2023

  We apologize for the delay in the refund.  We reached out to our accounting department and we have been told that Ms. ****** should see funds in her account tomorrow.  Thank you.

   

  Customer response

  02/12/2024

  Back on august 15th 2023 I had originally filed this complaint with the BBB While applying for health insurance on, June 30th 2023, Moda employees informed me that I would not be eligible for insurance for July. That it was too quick of a turn around time but that I should have insurance by August. I still had not heard anything from MODA by August. On August 4th I received a call about my coverage stating that they received the paperwork but that they needed more information as to why my insurance was canceled. I provided the information and was told that I had insurance for August. I then received a bill for July. I called and spoke with ********************* who informed me that they had backdated my insurance and that I was covered for July even though I was told that I was not covered for July. Even assured me I would not be charged for July since they told me that I was not covered. I was then charged for July anyways. After speaking with a representative today I was told that she would put in a request to refund my money but that she couldnt guarantee I would be refunded because I have no proof. My refund was issued and my complaint was resolved. Then my insurance was canceled without notice. I had signed up for auto pay and was receiving letters from MODA about policy changes for the upcoming year (2024). I had also received my insurance card and letters letting me know my auto pay was drafted. I had no reason to believe my insurance had been canceled. I was reviewing my benefits online today to find that my policy was no where to be found. I called MODA and was told that I dont have a policy with them. They then told me that my policy was canceled in august because they needed more information about my previous policy being canceled. I explained that I was in contact with ***********************, he had requested additional information back in august and I emailed him that information. He told me the information had been accepted and everything was fine. I have records.

  Business response

  02/26/2024

  Thank you. 

• Initial Complaint

  06/09/2023

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  I have continually communicated with various agents at Moda Health requesting receipt information to submit to the *************************** for financial assistance.I have been trying to get this information for about 3 months now. Every time I get a response from Moda Health I receive information that is not what I asked for.I am currently waiting for a call back from a manager or supervisor. I was told they are all in a meeting and will call me back within 24 to 48 hours.This request is not that complicated, I need receipts showing the payments I made toward my premiums from January to present so I can be reimbursed by ***.*** requests specific information on the documents and I explained this to Moda Health agents and everything they have sent me does not come close to what I requested.My previous Health insurance companies have all been able to supply this documentation. Since I have moved to Oregon and been a customer of ********************** I have been having this problem.Attached is the screen shot from the *** website showing the denial of my request for reimbursement from previous attempts to get this documentation from Moda Health.Also attached is the most recent document sent to me from Moda Health. It is not what I requested, it does not include most of the information that I asked for.Each time I go through this process the agent that listens to my request, or if I send an email or letter, it is not what I need. All I want is to be able to get the documentation showing what I pay for my premiums. It has to be from Moda Health and adhere to the parameters shown on the screen shot taken from my *** portal.

  Business response

  06/22/2023

  Thank you.

• Initial Complaint

  05/02/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  Moda has been my medical insurance carrier since January 1, 2023. On January 6 and 24, respectively, I saw ********** health provider for follow-up visits. Section 7.4.8 of the Moda member handbook (see link below) states that "[a] woman may see a womens healthcare provider instead of the *** 360 for preventive womens health exams. This includes follow-up visits resulting from an exam covered under this provision." **** failed to pay the claims for these visits accordingly, however, treating them instead as specialist office visits to which my deductible would apply. As a result, I am being charged approximately $500 out of pocket for these visits. My complaint: I believe that **** is failing to do what its member handbook states it will do for individuals who are covered under its *** 360 plan, which is to effectively treat follow-up visits with women's healthcare providers as if they were follow-up visits with a primary care provider. ****'s failure to do so has created unplanned and unexpected out-of-pocket medical expenses for me as the consumer, which is negatively impacting my family budget and creating undue stress. ********************************************************************************************************************************

  Business response

  05/11/2023

  Please see the attached response.  Thank you.  

  Customer response

  05/12/2023

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

• Initial Complaint

  04/12/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  My GI specialist has been seeking authorization from Moda for the recommended course of treatment. Moda required that I first try other, cheap medications that are not specific to my condition before they would consider covering the more expensive, specific medication. I tried and failed two medications as directed. My GI reported that after this was complete, they applied again for authorization, and that **** responded that they are refusing to consider this issue any further. The prior authorization case number I was given was B7KUYKBV. I have received zero communication from Moda about this case. I have full coverage from Moda and have for years, and this is not the first time they have been reluctant to or outright refuse to provide the care that is described in their literature. Another time, for a separate issue, they went so far as to say that despite the coverage being described as a $100 copay on their website (I sent a screenshot), because it was described as being covered at 80% (I think) in the patient handbook, it was ok that they covered it at 80%.

  Business response

  04/20/2023

  Thank you.

  Customer response

  04/26/2023

   
  Complaint: 19929515
  
  I am rejecting this response because:

  **** stated in its response to the BBB complaint that "Moda Health sent a letter dated April 10, 2023 to **************** that the request was closed due to all prior authorization reviews have been exhausted for Xifaxan. **************** was referred to review the prior denial letter for instruction on how to file an appeal."

  As directed by the PA denial from Moda dated 1-31-23 (referenced within Moda's response to the BBB complaint), further steps in trialing and failing medications have been completed by the patient (myself), and thus the PA for ******* as submitted 4-6-23 or 4-12-23 by *************************** FNP can be reconsidered.
  
  Sincerely,
  
  *****************************

  Business response

  05/10/2023

  In the response sent to your office on April 20, 2023 we advised what the member needed to do in order to have this concern reviewed.  At this time the member needs to write in a letter of appeal to Moda Health.  The member can provide any clinical information to support the appeal.  Appeal rights were provided in the denial letters sent to the member and are in the member handbook should have further questions about the appeal process.  Thank you.

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩