Member's Frequently Asked Questions
- How do I know what plan I have?
- Can I view my plan summary/benefit online?
- Can I choose a primary care physician (PCP) or specialist online?
- What do I do if my doctor/dentist no longer participates with ODS and I want to continue seeing him/her?
- Do I have to call Customer Service to update my account or can I do it through the web site?
- How do I add /drop a member of my family on my plan?
- I have other group coverage, will ODS coordinate benefits?
- My coworker 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?
- What do I have to do to sign up my new baby on 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?
How do I know what plan I have?
Look on the top of your ID Card or your Member Handbook and it will say what type of plan you have and what network you can use.
Can I view my plan summary/benefit online?
Yes, you can view your summary/benefit information online by accessing our member website, myODS, for information on your plan. You can also download your Member Handbook.
Can I choose a PCP or specialist online?
Yes, you can select a PCP online. To find a physician in your area, go to our provider directory. If you're signing up for a new PCP be sure to contact the physician's office to verify that they are accepting new patients. When you have selected a PCP who is accepting patients, contact Customer Service or register online. A new ID card will be sent to you within 5-10 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 can find specialists online as well through the provider 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/dentist no longer participates with ODS and I want to continue seeing him/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 may also contact Medical Customer Service for information.
Dental: Under most ODS plans, you are able to see any licensed dentist whether their status is participating or not. Please contact 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 web site?
You can request an ID Card, change your address, and change your PCP by filling out the online form. You can also contact Customer Service.
How do I add/drop a member of my family on my plan?
To add a dependent to your plan you will need to contact the human resource department for your company. To drop a dependent this same procedure will need to be followed. The only time ODS will drop a dependent automatically is when they exceed the age limit(s).
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 we know to coordinate benefits. Please contact Customer Service for more information.
My coworker has a question, but he doesn't speak English very well. Can you help?
Yes, we can help for all medical and dental plans and for Oregon Health Plan dental customers. Simply have your coworker contact Customer Service. One of our representatives will coordinate the services of an interpreter over the telephone.
What if I'm not sure if I have medical or dental eligibility?
To verify your eligibility, you or your provider should contact Customer Service.
What do I have to do to sign up my new baby on a plan?
You have the option of adding your baby to your plan for 31 days from the date of 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 Customer Service.
How do I order an ID card?
To order a new medical or dental ID card contact Customer Service or fill out our online form. If you have purchased an individual dental plan, please contact Customer Service.
How do I read my Explanation of Benefits (EOB)?
We have provided a Medical and Dental Explanation of Benefits (EOB) (PDF File) sample for you to read.
What is the address for filing a claim?
Medical Claims
ODS Companies
PO Box 40384
Portland, OR. 97240-0384
Dental Claims
ODS Companies
601 SW 2nd Avenue
Portland , OR 97204
Please be sure the following information is included:
- 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 explaining 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.
Maximum Plan Allowance (MPA) is the maximum amount that ODS will reimburse physicians and providers. For an in-network physician/provider, the maximum amount is the amount the provider has agreed to accept for a particular service.
For a service by an out-of-network physician/provider, ODS will process charges for those services as follows: maximum amount is the lesser of the amount payable under any supplemental provider fee arrangements we may have in place and the seventy-fifth (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 seventy-five (75) percent of the billed charge as MPA. The remaining twenty-five (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.
In each of the above situations relating to an out-of-network physician/provider, any amount above the MPA is patient responsibility. Depending upon the Plan provisions deductibles and co-insurance may apply.
Please call our Medical Customer Service representative at 503-265-2966 or 1-888-873-1383 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 web site where you might find the information you're looking for. Look at your Member Handbook, which outlines your plan's details. Or read some of the other Frequently Asked Questions. You can always contact your benefits department or contact Customer Service.