Are you unhappy with Family Dental Care, Inc., your care, or dentist? You can complain or file a grievance at any time. “Appeals and Grievances Policies and Procedures” explains in detail how to file a complaint, grievance or appeal. If you would like a copy of our Policies and Procedures, call Customer Service.
With your written permission an authorized representative or provider can file for you. If a provider supports you in a complaint, we will not take any negative action against him/her. When receiving a complaint, we will try to make things better. Call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711.
Member can file grievance and/or appeal in writing or orally. (If oral don’t need to follow-up in writing).
Provider or authorized rep (with member’s permission) can file grievance and/or appeal on member’s behalf.
If provider has filed appeal on member’s behalf provider can request administrative hearing.
If we do not follow required timeframes for appeal resolution or extension of time member
You can send us a fax at (503) 644-6488. Or a letter, our mailing address is:
Family Dental Care, Inc.
6700 SW 105th Ave.
Beaverton, OR 97008
You may also file a complaint with OHP Client Services by calling (800) 273-0557. Or the Oregon Health Authority’s Ombudsman at (503) 947-2346 or toll free at 877-642-0450.
You may to file a grievance and request that your personal identification information not be shared. This will help protect members from back lash but may slow down solving your problem.
Family Dental Care, Inc. will work to resolve your complaint or grievance within five business days. Sometimes we need more than five days. Then we will send you a letter to let you know why. You will receive a final answer within 30 calendar days. We will not tell anyone about your complaint unless you ask us to.
Appeals and Hearings – At times we will deny, stop or reduce a medical service your provider has ordered. In that case we will explain why we made that decision. The explanation will come by mail in a Notice of Action letter. You have a right to ask to change it through an appeal and a state fair hearing. You must ask for an appeal. It must be requested no more than 60 days from the date on the Notice of Action letter.
If we deny, stop or reduce a service your provider has requested we will mail you a denial letter. The letter will be saying Notice of Adverse Benefit Determination near the top of the page. It will explain why we made that decision. You have a right to ask for the decision to be changed. This can be done through an appeal and a state fair hearing. You must ask Family Dental Care, Inc. for an appeal. It can be no more than 60 days from the date on the denial letter. With your written permission an authorized representative or provider can file for you.
In an appeal Family Dental Care, Inc. will look at your case again. We may receive additional information. A different dental professional at Family Dental Care, Inc. will review the documentation. This may change the decision. Ask us for an appeal by:
- Calling Customer Service Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711.
- Writing us a letter.
- Filling out an Appeal and Hearing Request, OHP form OHP 3302 or MSC 443.
Do you want help filing an appeal? Call and we can fill out an appeal form for you to sign. You can ask someone like a friend or case manager to help you. You may also call the Public Benefits Hotline at (800) 520-5292. They provide legal advice and help.
With your written approval a provider can file an appeal for you. If a provider supports you in an appeal we will not take any negative action against the provider.
You will get a Notice of Appeal Resolution from us in 16 days. This will let you know if the reviewer agrees or disagrees with our decision. Occasionally we need more time to do a good review. Then we will send you a letter saying why we need up to 14 more days.
Family Dental Care, Inc. is required to process your appeal within 16 days or by the extended appeal timeframe. If we do not this means the appeal process has been exhausted and you can file for an administrative hearing. You don’t have to file your own appeal. If you wish, an authorized (approved) representative can file a grievance for you.
You can keep on getting a service that already started before our decision to stop it. You must ask us to continue the service. This must be within 10 days of getting the denial letter that stopped it. If you continue the service two things can happen.
- The reviewer changes the original decision. The service is approved and OHP will pay for the service.
- The reviewer agrees with the original denial. The services are still denied. You may have to pay the cost of the services that you received. This will be for services after the Effective Date on the denial letter.
Your provider can appeal for you. This can happen when their dentist’s orders are denied by a plan. You must agree to this in writing.
After an appeal you will receive a Notice of Appeal Resolution (NOAR). It will tell you if your appeal was upheld or overturned. After a member receives an adverse appeal decision a hearing can be filed. Was your appeal for services denied? Were your appeal rights exhausted because we did not keep to the time frames? Then you can ask for a state fair hearing with an Oregon Administrative Law Judge. You will have 120 days from the date on your NOAR to ask the state for a hearing. Your NOAR letter will have a form that you can send in. You can also ask us to send you an Appeal and Hearing Request form. Call OHP Client Services at (800) 273-0557, (TTY) 711, and ask for form OHP 3302 or MSC 443.
If a provider files an appeal on your behalf, they can request a hearing on your behalf.
At the hearing, you can tell the judge why you do not agree with our decision. Also, why you think the services should be covered. A lawyer is not required, but you can get someone else to help you. This person can be a lawyer or a dental professional. The member must provide written consent. If you hire a lawyer, you must pay their fees. You can ask for help from the Public Benefits Hotline. It is a program of Legal Aid Services of Oregon and the Oregon Law Center. Contact them at (800) 520-5292, (TTY) 711. They can give advice and possible representation. Information on free Legal Aid can also be found at https://oregonlawhelp.org/ .
A hearing can take more than 30 days to prepare. You can keep on getting a service that already started before our original denial until then. You must ask the state to continue the service. It must be within 10 days of getting our NOAR that confirmed our denial.
- If you continue the service and the judge agrees with the denial the services are still denied. You may have to pay the cost of the services that you received. This will be for services after the date on the NOAR.
Do you and your PCD feel you have an urgent problem? One that cannot wait for a regular appeal. Tell us. You can ask for an expedited (fast) appeal. We suggest you have your PCD explain to us its urgency. You can include a statement from your PCD. You or your PCD can call or email us. If we agree that it is urgent, the appeal will be expedited. We will call you with a decision within 72 hours of receipt of the appeal. For the quickest results, you can fax your appeal form to (503) 644-6488. Or you can send it by mail: Family Dental Care, Inc. 6700 SW 105th Ave., Beaverton, OR 97008.
Also, you may request an expedited (fast) hearing from OHA. Fax your hearing request form to: OHP Hearings Unit at (503) 945-6035. Include a statement form (form OHP 3302 or MSC 443) from your provider explaining why it is urgent. If OHP agrees that it is urgent, the Hearings Unit will call you in three workdays.
If you are denied services and do not receive a written notice of denial. Or your provider tells you to pay for a not covered service without your having signed a payment waiver. You or your representative can ask for a denial written notice letter. Once you receive the denial notice you can ask for an appeal with us. You or your representative can ask Family Dental Care, Inc. to send you a denial notice if you did not receive one.
At the back of this handbook, you will find a template of Family Dental Care, Inc.’s denial notice.
IMPORTANT TO KNOW: Family Dental Care, Inc. will not affect continuation of service while you appeal a decision. However, you may have to pay for services delivered during the appeal process. This is if the decision to deny or limit the service is upheld.