Member frequently asked questions
- How do I know what plan I have?
- Can I view my plan summary and benefits online?
- Can I choose a primary care physician (PCP) or specialist online?
- What if my doctor or dentist no longer participates with ODS and I want to continue seeing him or her?
- Do I have to call ODS Customer Service to update my account or can I do it through the website?
- How do I add or drop a member of my family on my plan?
- I have other group coverage — will ODS coordinate benefits?
- My co-worker has a question, but he doesn't speak English very well. Can you help?
- What if I'm not sure if I have medical or dental eligibility?
- How do I sign up my new baby for a plan?
- How do I order an ID card?
- How do I read my Explanation of Benefits (EOB)?
- What is the address for filing a claim?
- How does ODS determine the allowable amount for medical services and procedures?
- What if the answers to my questions are not here?
- I can't find my provider, is there a list of providers that have ended their contract with ODS?
How do I know what plan I have?
The type of plan you have and what network you can use is printed at the top of your ID card as well as on the cover of your Member Handbook. You can access your Member Handbook and other account information by logging in to your myODS account.
Can I view my plan summary and benefits online?
Yes, you can view your summary and benefit information online by accessing your member website, myODS. You also can download your Member Handbook from myODS to view this information.
Can I choose a primary care physician (PCP) or specialist online?
Yes, you can select a primary care physician (PCP) online. To find a physician in your area, go to our find care directory. If you're signing up for a new PCP, be sure to contact the physician's office to verify that he or she is accepting new patients. When you have selected a PCP who is accepting patients, contact ODS Customer Service or register online. A new ID card will be sent to you within five to 10 working days. You can change PCPs up to two times per year. Remember, your new PCP is effective at the beginning of the next month.
You also can find specialists online through the find care directory. Depending on your plan type, you may need a referral to see them. If that is the case, your PCP will refer you for specialty care, including both physician and hospital services.
What do I do if my doctor or dentist no longer participates with ODS and I want to continue seeing him or her?
Medical: Your plan may have a continuity of care provision that will enable you to continue care with the physician for a limited period of time. If continuity of care applies to your plan, it will be described in your Member Handbook. You also can contact ODS Medical Customer Service for information.
Dental: Under most ODS plans, you can see any licensed dentist whether his or her status is participating or not. Please contact ODS Dental Customer Service for assistance with a provider search and for additional questions.
Do I have to call customer service to update my account or can I do it through the website?
You can request an ID card, change your address and change your PCP by filling out the online form. You also can contact ODS Customer Service to take care of these tasks. If your group is an electronic file group, please contact your human resources department to make the address change.
How do I add or drop a member of my family on my plan?
To add or drop a dependent on your plan, you will need to contact your employer’s HR department. The only time ODS will drop a dependent automatically is when he or she exceeds the age limit.
I have other group coverage — will ODS coordinate benefits?
Generally, yes. It is important that you notify us of your other group coverage on your medical and dental enrollment forms so that we know to coordinate benefits. Please contact ODS Customer Service for more information.
My co-worker has a question, but he doesn't speak English very well. Can you help?
Yes, we can help for all medical, pharmacy and dental plans, and for Oregon Health Plan dental and medical customers. Simply have your co-worker contact ODS Customer Service, and one of our representatives will coordinate the services of an interpreter over the phone.
What if I'm not sure if I have medical or dental eligibility?
To verify your eligibility, you or your provider should contact ODS Customer Service. Your provider also can check your eligibility by visiting our website and logging on to Benefit Tracker. Providers must be participating in our free Benefit Tracker program to check your eligibility online.
How do I sign up my new baby for a plan?
Congratulations on your new arrival! You have the option of adding your baby to your plan. You must add your baby within 31 days of his or her birth. You will need to contact your employer as soon as possible so that the baby can be enrolled on the group plan. If you have purchased an individual plan, please contact ODS Customer Service.
How do I order an ID card?
An ID card will be sent to you upon enrollment in an ODS plan. To order a new medical or dental ID card, please log on to myODS and select "Request ID cards" from the member shortcuts panel. You also can contact ODS Customer Service. If you have purchased an individual dental plan, please contact ODS Customer Service.
How do I read my Explanation of Benefits (EOB)?
We have provided a dental and medical Explanation of Benefits (EOB) sample for you to read.
What is the address for filing a claim?
Medical claims
ODS
P.O. Box 40384
Portland, OR 97240-0384
Dental claims
ODS
601 S.W. 2nd Ave.
Portland, OR 97204
Pharmacy claims
ODS
P.O. Box 40168
Portland, OR 97240
Major medical groups, please submit your pharmacy claims to:
ODS
P.O. Box 40384
Portland, OR 97240-0384
Please include the following information:
- Patient's name, identification number and group ID number
- Date of treatment
- Diagnosis (medical only)
- An itemized description of services and charges
If the treatment is for an accidental injury, include a statement with the date, time, place and circumstances of the accident when you send us the physician or professional provider's bill.
How does ODS determine the allowable amount for medical services and procedures?
ODS uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures.
MPA is the maximum amount that ODS will reimburse physicians and providers. For an in-network physician or provider, the maximum amount is the amount the provider has agreed to accept for a particular service.
For service by an out-of-network physician or provider, ODS will process charges for services as follows: the maximum allowable amount is the lesser of the amount payable under any supplemental provider fee arrangements we may have in place and the 75th percentile of fees commonly charged for a given procedure in a given area, based on a national database.
If a dollar value is not available in the national database, ODS will consider 75 percent of the billed charge as MPA. The remaining 25 percent over the MPA is the patient’s responsibility.
In certain instances, when a dollar value is not available in the database, the claim is reviewed by the ODS Medical Consultant, who determines a comparable code to the one billed. Once a comparable code is established, the claim is processed as described above.
For services provided by an out-of-network physician or provider, the amount above the MPA is the patient’s responsibility. Depending on the plan, provisions deductibles and coinsurance may apply.
Please call ODS Medical Customer Service if you have any additional questions or concerns. We will be happy to help answer your questions.
What if the answers to my questions are not here?
If you can't find answers to your questions here, we offer other options on our website where you might find the information you're looking for. For instance, your Member Handbook outlines your plan details. You can access your Member Handbook by logging on to myODS. You also can contact your benefits department for more information or call or e-mail the ODS Customer Service team.
I can't find my provider, is there a list of providers that have ended their contract with ODS?
Yes, please visit our list of ODS termed providers.
Log in to Benefit Tracker
Check benefits and eligibility
Log in to Benefit Tracker
Check benefits, eligibility, incentive and utilization
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