Oregon Health Plan general FAQs
- What is considered a medical emergency?
- What if members are not sure if they have medical eligibility?
- How do I appeal a denied or reduced claim?
- Do members need a referral for routine services such as vision or gynecology exams?
- 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 Oregon Health Plan claims?
- How do I get information in the physician directories updated?
What is considered a medical emergency?
An emergency medical situation is defined as a condition producing symptoms severe enough that a person’s well-being is in serious jeopardy — as judged by any reasonable person with an average knowledge of health and medicine. Emergencies also apply to a fetus in the case of a pregnant woman.
What if members are not sure if they have medical eligibility?
You can verify eligibility on an ODS OHP member in the following ways:
- Log on to Benefit Tracker. Benefit Tracker is available seven days a week from 6 a.m. to 10:30 p.m., including holidays.
- Call DMAP’s Automated Voice Response System (AVR) at 866-692-3864.
- Use DMAP’s Provider Web Portal.
- Call ODS Customer Service at 888-788-9821. You can reach ODS Customer Service Representatives Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific time, excluding holidays.
- Contact ODS by e-mail. You need to identify yourself, your patient and the issue. Our goal is to send a response within 24 hours. Our e-mail correspondent’s hours are Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific time, 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 or reduced claim?
First contact ODS 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 gynecology exams?
No, members can self refer to a participating optometrist for vision services or an OB/GYN for routine annual women's exams and maternity care. Members also can 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?
Yes. 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, members should contact ODS Customer Service. A new ID card will be sent to the patient within five to 10 working days.
What are the timely filing requirements for OHP claims?
ODS requires that all eligible claims for covered services are received in our office within 120 days after the date of service. If a claim falls into one of the following categories, 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 ODS Medical Professional Relations.
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