ODS Point of Service (POS)

Under a Point of Service plan, participants can choose a Primary Care Physician (PCP) to help manage their healthcare. The PCP manages all of your healthcare including referrals to specialists and hospitals, and emergency care if you need it. At any time, day or night, 365 days a year, your PCP assumes the primary responsibility for medical care. Should your PCP be unavailable, he or she will arrange for another participating physician to assume responsibility for your care. If you are treated for medical services from a provider without having gone through your PCP, your claims will be paid at the out-of-network benefit level and your responsibility for the cost associated with those claims will be higher than if you had coordinated your care through your PCP.

Value-Added Services

The following services are provided to ODS plans at no additional cost.

myODS

With myODS, our customized member website, you can:

Preview myODS

The following services are provided to ODS medical plans at no additional cost.

eDoc America

eDocAmerica provides unlimited communication with board certified physicians via secure e-mail. This service gives you access to physicians who can answer questions about and assist you with healthcare choices.

Registered Nurse Advice Line

The Registered Nurse Advice Line provides 24/7 access to a registered nurse (RN) who can answer your healthcare questions regarding symptoms, medications, medical tests, procedures and staying healthy.

PersonalHealth Rx

PersonalHealth Rx gives members online access to detailed claims history, benefit information and tax reports.

Free & Clear

We are proud to offer an effective tobacco cessation program to employers. The Free & Clear Quit For Life program, which has been in existence for 20 years, is based on scientific evidence that supports reduced tobacco use through telephone counseling, nicotine replacement therapy and prescription drugs.

The following service is provided to ODS medical plans for an additional cost.

ODS Wellness

We’ve taken a positive step by expanding ODS health promotion offerings with ODS Wellness. This OHSU-partnered program is a means of pro-active health care and disease prevention that can improve and retain the health and well-being of your employees. For more information on this all-inclusive, comprehensive wellness program, contact

Third Party Administration

Additionally, the following services are provided through our subsidiary, BenefitHelp Solutions.

Frequently Asked Questions About Point of Service (POS) Plans:

How do I choose a primary care physician (PCP)?

ODS' POS network includes over 6000 primary care physicians and specialists. To find a PCP in your area, go to our provider directory. Be sure to contact the physician's office to verify that they are accepting new patients. Also, make sure you select a PCP from the correct network for your plan (your plan is noted on your ID card and in your member handbook). ODS contracts with several networks to provide more physician choices and geographic areas.

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Can each of my family members select a different PCP?

Yes, each family member covered under the medical plan can select a different PCP.

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How do I change from one PCP to another?

You have the option of changing primary care physicians within your plan's network twice in a 12-month period. The change will be effective the first of the month following the date of the request. When you have selected a PCP who is accepting patients, contact our customer service department or fill out the online form. A new ID card will be sent to you within 5-10 working days.

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Will I be informed if my PCP is no longer participating in the network?

In the event your PCP is no longer participating in the network, we will mail you information with instructions on how to change your PCP.

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What happens when I need specialty care?

Your PCP will refer you for specialty care, including both physician and hospital services. Exceptions: women may go directly to a participating obstetrics/gynecologist for annual exams and maternity care without a referral.

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How do I know when I need a referral?

Generally a referral is needed if you go to any physician or provider other than your PCP. If you go to a physician or provider without obtaining a referral from your PCP, your benefits may be reduced or denied. If your PCP believes that you need the services of another physician or provider of healthcare, usually he or she will refer you to a participating physician or provider.

There are exceptions to the referral requirement under a Point of Service plan. A referral is not needed if you are seeking emergency medical treatment, or if you are a woman who is using the services of a participating women's healthcare provider for either a routine women's exam or for routine maternity care. A referral is not needed for chemical dependency or mental health treatment. However, you must contact your plan's chemical dependency/mental health coordinator for preauthorization.

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I am new to ODS and am glad to see that my current PCP is participating in the network for my plan. Because I am not changing doctors, do I need to get new referrals?

With a new insurance carrier, historical information regarding records of referrals insures members and preauthorizations do not follow. You should notify your PCP that your insurance coverage is now with ODS and ask him or her to call ODS with your referral information.

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How will my dependent children who live outside of the service area be covered by this plan?

While an insured dependent child under age 23 resides outside the service area, we will extend Plan benefits for treatment of an illness or injury, and preventive healthcare and maternity services, as if the care were rendered by participating physicians or providers, subject to the following limiations:

A referral from a primary care physician is not required for an out-of-area dependent child to receive benefits for medically necessary care. However, a dependent's PCP should be notified of such treatment as required for other emergency or urgent care services received outside the service area.

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What do I do in case of an emergency?

In the event of an emergency, you are covered worldwide 24 hours a day. Emergency medical condition means a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person, or a fetus in the case of a pregnant woman, in serious jeopardy.* In such a case, you should proceed to the closest medical facility for care. You should call your PCP within 24 hours of the initial medical care, or as soon thereafter as possible, so he or she can coordinate your care. Routine care or follow-up care will NOT be covered out of area at the in-network benefit level unless authorized by your PCP.

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What do I do if I need urgent care?

Use of an emergency room for urgent but non-emergency care may not be covered at the highest POS benefit level unless authorized by the PCP. Urgent care means immediate, short-term medical care for minor but urgent medical conditions that do not pose a significant threat to life or health at the time the services are rendered. Call your PCP if you need urgent care. He or she will tell you how to proceed.

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What if I or one of my enrolled family members needs mental health or chemical dependency services?

The ODS Mental Health and Chemical Dependency Programs are coordinated by Cascade Behavioral Health which has composed a provider network consisting of psychiatrists, psychologists, licensed clinic social workers, and other mental health professionals. These professionals work together with private and community programs to provide individual treatment. Please call Cascade Behavioral Health at 1-800-799-9391 when you feel in need of assistance. There is no requirement to contact your PCP first.

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What if I or one of my enrolled family members is currently receiving mental health or chemical dependency services?

It is important that you contact Cascade Behavioral Health at 1-800-799-9391. This is necessary to coordinate ongoing care and ensure your provider of service is participating with Cascade Behavioral Health. In addition, this will ensure you receive the highest level of benefit available under your health plan.

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*This is our standard contract wording, your plan may be different so please reference your member handbook for what applies to your plan.