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Oregon Health Plan (OHP) General FAQs
- What is considered a medical emergency?
- What if a member is not sure if they have medical eligibility?
- How do I appeal a denied and/or reduced claim?
- Do members need a referral for routine services such as vision, GYN/ PAP , etc.?
- Does an existing patient who is new to ODS need new referrals?
- Can each family member select a different PCP?
- How does a patient change from one PCP to another?
- What are the timely filing requirements for OHP claims?
- How do I get information in the physician directories updated?
What is considered a medical emergency?
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.
What if a member is not sure if they have medical eligibility?
There are several ways to verify eligibility on an ODS OHP member.
- Option 1: Call DMAP’s Automated Voice Response System (AVR) at 866-692-3864.
- Option 2: Use DMAP’s Provider Web Portal.
- Option 3: Use Benefit Tracker. Benefit Tracker is available seven days a week from 6:00 am to 10:30 pm, including holidays.
- Option 4: Call ODS Customer Service at 1-888-788-9821. You can reach customer service Monday through Friday from 7:30 am to 5:30 pm, excluding holidays.
- Option 5: Contact ODS by e-mail : . You need to identify yourself, your patient and what the issue is. Our goal is to send a response within 24 hours. Our e-mail correspondent’s hours are Monday through Friday from 7:30 am to 5:30 pm, excluding holidays.
NOTE: Access to the AVR and the Provider Web Portal require a Medicaid provider number and PIN. Contact DMAP Provider Services at 800-336-6016 to enroll.
How do I appeal a denied and/or reduced claim?
First contact customer service at 888-788-9821. If they cannot adjust the claim to pay based on any new information you give them, then you can mail an appeal letter to the ODS Complaint Management Department. The letter should state clearly and concisely why you feel it should have been paid or paid at a higher level. Chart notes or other medical documentation should be included with the appeal letter.
Do members need a referral for routine services such as vision, GYN/ PAP , etc.?
No, members can self refer to a participating optometrist for vision services or an OB/GYN for routine annual women's exam and maternity care. Members can also self refer to participating providers for family planning, immunizations and outpatient services for drug and alcohol problems.
Does an existing patient who is new to ODS need new referrals?
With a new insurance carrier, historical information regarding records of referrals and authorizations do not follow. Patients should notify their PCP that their insurance coverage is now with ODS and ask him or her to call ODS with your referral information.
Can each family member select a different PCP ?
Yes, each family member covered can select a different PCP .
How does a patient change from one PCP to another?
Patients have the option of changing their PCP up to two times every six months. The change will be effective the day the request is received by ODS. When they have selected a PCP who is accepting patients, they should contact customer service. A new ID card will be sent to the patient within 5-10 working days.
What are the timely filing requirements for OHP claims?
ODS requires that all eligible claims for covered services be received in our office within 120 days after the date of service. If a claim meets the following criteria ODS may waive the 120 day timely filing rule:
- Newborns
- Medicare coverage
- Other insurance coverage
- Claims denied by Workers Compensation
- Claims that are being processed or adjusted after retroactive eligibility changes
- Billing is delayed due to eligibility issues
- Pregnancy of the OMAP member
- Causes involving third party resources
How do I get information in the physician directories updated?
Send a message to professional relations.