MEMBER HANDBOOK

Effective January 1, 2022

In Partnership With

WELCOME

Family Dental Care, Inc. is glad you have become a member of our plan. We want you to know about your benefits and services. Knowing how to use them is key to getting the best care possible.

If you need help or have questions, call Customer Service at (503) 644-2663, or toll free at (888) 350-0996 (TTY) 711.

Do you have trouble speaking or understanding English? Do you need a sign language interpreter? You have a right to interpretation and the services are free.

NON-DISCRIMINATION POLICY

We must follow state and federal civil rights laws. We cannot treat people unfairly in any of our programs or activities because of a person’s:

AgeNational Origin
ColorRace
DisabilityReligion
Gender IdentitySex
Marital StatusSexual Orientation

Everyone has the right to enter, exit and use buildings and services. They also have the right to get information in a way they understand.

We will make reasonable changes to policies, practices and procedures by talking with you about your needs.

To report concerns or to get more information, please contact us in one of these ways:


Family Dental Care, Inc. must follow state and federal civil rights laws. We cannot treat people unfairly in any of our programs or activities for any reason. Some of these reasons are a person’s:

  • Age
  • Color
  • Disability
  • Gender Identity
  • Marital status
  • National origin
  • Race
  • Religion
  • Sex
  • Sexual orientation

If you think we or a dentist has treated you unfairly, please tell us. Contact our Compliance Officer by mail, phone, fax, or email. Do not send any Personal Health Information (PHI) by email. If you or your representative need help filing call Customer Service. You can also make a complaint by sending us a secure email using the ‘Contact Us’ section of our website.

  • Mailing address:

6700 SW 105th Ave

Suite 210

Beaverton, OR 97008

You also have a right to file a civil rights complaint. Contact the U.S. Department of Health and Human Services, Office for Civil Rights at:

  • Mailing address:

200 Independence Avenue SW

Room 509F HHI Bldg.

Washington, D.C. 20201

Or contact the Oregon Office for Civil Rights Office of Equity and Inclusion at:

  • Mailing address:

421 SW Oak, Suite 750

Portland, Oregon 97204

Or contact the Oregon Bureau of Labor and Industries at:

Oregon Bureau of Labor and Industries

800 NE Oregon Street, Suite 1045

Portland, Oregon 97232

More information on OHA 2993C, Non-discrimination Policy here: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le2993c.pdf.

LANGUAGE ACCESS STATEMENT

ENGLISH

You can get this document in other languages, large print, braille or a format you prefer. You can also ask for an interpreter. This help is free.

Program/contact: Family Dental Care, Inc. Customer Service

Phone: 503-644-6223 / 888-350-0996

Email: quality@familydentalcareinc.com  

We accept all relay calls or you can dial 711.

SPANISH / ESPAÑOL

Puede obtener este documento en otros idiomas, en letra grande, braille o un formato que prefiera. También puede solicitar un intérprete. Esta ayuda es gratuita.

Programa/contacto: Family Dental Care, Inc. Customer Service

Teléfono: 503-644-6223 / 888-350-0996

Correo electrónico: quality@familydentalcareinc.com  

Aceptamos llamadas de retransmisión o puede llamar al 711.

VIETNAMESE / TIẾNG VIỆT

Bạn có thể lấy tài liệu này bằng các ngôn ngữ khác, bản in lớn, chữ nổi hoặc định dạng bạn thích. Bạn cũng có thể yêu cầu thông dịch viên. Trợ giúp này là miễn phí.

Chương trình/liên lạc:

Family Dental Care, Inc. Customer Service

Số điện thoại: 503-644-6223 / 888-350-0996

Email: quality@familydentalcareinc.com  

Chúng tôi chấp nhận tất cả các cuộc gọi chuyển tiếp hoặc quý

vị có thể bấm số 711.

RUSSIAN / РУССКИ

Вы можете получить этот документ на других языках, крупным шрифтом, шрифтом Брайля или в другом формате. Вы также можете попросить переводчика. Эта помощь бесплатна.

Название программы и контактное лицо: 

Family Dental Care, Inc. Customer Service

Телефон: 503-644-6223 / 888-350-0996

Эл. почта: quality@familydentalcareinc.com  

Мы отвечаем на любые вызовы по линии трансляционной связи; кроме того, вы можете набрать номер 711.

ARABIC / اللغة العربية

يمكنك الحصول على هذا المستند بلغات أخرى ، أو بحروف كبيرة ، أو بطريقة برايل ، أو بالتنسيق الذي تفضله. يمكنك أيضًا طلب مترجم. هذه المساعدة مجانية.

Family Dental Care, Inc. Customer Service البرنامج/ الاتصال:

503-644-6223 / 888-350-0996هاتف:

 البريد الإلكتروني (الإيميل):

quality@familydentalcareinc.com  

نستقبل جميع المكالمات الهاتفية المعمولة بواسطة خدمات الاتصال المكتوب

.711 أو يمكنكم الاتصال بالرقم (relay calls)

BURMESE / ဴမန္မာ

ဤစာတမ်းကိုအခြားဘာသာစကားများ၊ ပုံနှိပ်စာလုံးကြီးများ၊ မျက်မမြင်စာ (သို့) သင်ကြိုက်နှစ်သက်သောပုံစံဖြင့်ရနိုင်သည်။ စကားပြန်တစ် ဦး ကိုသင်တောင်းနိုင်သည်။ ဤအကူအညီသည်အခမဲ့ဖြစ်သည်။ အစီအစဥ္/အဆက္အသၾယ္ – Family Dental Care, Inc. Customer Service

ဖုန္းနံပၝတ္ – 503-644-6223 / 888-350-0996

အီးေမးလ္ – quality@familydentalcareinc.com

တဆင့္ဆက္သၾယ္သည့္ ဖုန္းေခၞဆိုမႁမဵား အားလံုးကို က႗ႎ္ုပ္တိုႚ လက္ခံပၝသည္။ သိုႚမဟုတ္ 711 ကို သင္ဆက္ႎိုင္ပၝသည္။

SIMPLIFIED CHINESE

您可以获得其他语言版本的文档、大字体、盲文或您喜欢的格式。 您也可以要求翻译。 该帮助是免费的。

计划/联系人： Family Dental Care, Inc. Customer Service

电话： 503-644-6223 / 888-350-0996

电子邮箱： quality@familydentalcareinc.com  

我们会接听所有转接电话，或者您可以拨打 711。

TRADITIONAL CHINESE / 繁體中文

您可以獲得其他語言版本的文檔、大字體、盲文或您喜歡的格式。 您也可以要求翻譯。 該幫助是免費的。

計畫/連絡人：Family Dental Care, Inc. Customer Service

電話：503-644-6223 / 888-350-0996

電郵：quality@familydentalcareinc.com  

我們會接聽所有傳譯電話，或者您可以撥打 711。


MEMBER INFORMATION

CONTACT US

Our office is open Monday through Friday each week. It opens at 9:00 a.m. and closes at 5:00 p.m. each day. Family Dental Care, Inc. is closed on the following holidays:

  • New Year’s Day
  • Memorial Day
  • Fourth of July
  • Labor Day
  • Thanksgiving (Thursday and Friday)
  • Christmas

You can reach Customer Service by phone, fax, mail, or email.

  • Phone at (503) 644-2663
  • Toll free at (888) 350-0996
  • Hearing impaired (TTY) 711
  • Fax at (503) 644-6488
  • Mailing address is: 

Family Dental Care, Inc.,

6700 SW 105th Ave

Suite 210

Beaverton, OR 97008

Family Dental Care, Inc. Member Handbook is available in other formats. You, or someone helping you, can request a free member handbook in large print or another format. It can be requested in a different language. We provide these services at no cost to you. Call Customer Service at (503) 644-2663, or toll free at (888) 350-0996 (TTY) 711. Or email us at quality@familydentalcareinc.com.

VIEW, DOWNLOAD, OR PRINT MEMBER HANDBOOK

Our Member Handbook can be viewed, downloaded, or printed online. You can find and download the Member Handbook on our website.  Go to: https://www.familydentalcareinc.com/dco-members/.

IF YOU NEED AN INTERPRETER

You or your representative can ask for a certified or qualified spoken or sign language interpreter. We can also provide written translations or auxiliary aids and services. These services are provided to you or your representative free of charge.

If you or your representative need an interpreter at your dental visit, tell your provider’s office. Tell them what language you need help in. Your provider will contact us to arrange an interpreter.

We provide language and sign language interpreter services free of charge. Auxiliary aids are also provided free of charge. You can request these services by calling Customer Service.

More information on certified Health Care Interpreters can be found at:  https://www.oregon.gov/OHA/OEI/Pages/index.aspx.

NEW MEMBERS

Family Dental Care, Inc. will send new member materials within 14 days of enrollment. New member materials include a Welcome letter, Member Handbook, Provider Directory and Notice of Non-Discrimination. It will have directions on how to access and download the Member Handbook.

You can find and download the Member Handbook on our website. Go to: https://www.familydentalcareinc.com/dco-members/. We also include a Family Dental Care, Inc. member ID card in the packet for easy reference.

We can help new dental plan members. This includes new Medicare enrollees. If you need dental services within the first 30 days of enrollment, Call Customer Service. (See section ‘What to Do if you are New to Family Dental Care, Inc.’ for more information).

Member Materials

Member materials include our Member Handbook, and Provider Directory (list). We also have other materials available, such as oral health prevention information. As well as some of our policies and procedures.

If you want materials sent by email, you or someone helping you must give us an okay. To ask for and get member materials electronically call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711. Let us know which documents you would like emailed to you. Materials requested electronically will be sent within five (5) days of your request.

Download your copy of our Member Handbook. It gives detailed information on how you can get the most out of your dental care. Regardless of the format, copies of the Member Handbook are always ‘free of charge’.

Right To Use Our Programs and Services

All members have a right to know about and use our programs and services. The following assistance is available free to you and someone helping you:

  • Sign language interpreters
  • Qualified and certified spoken language interpreters for other languages
  • Braille
  • Member Materials and Written materials in other languages
  • Large print
  • Audio and other formats

And any way that works best for you.

Getting The Handbook in Another Format

You or someone helping you may ask for member materials in the language and format of your choice. Every format will include the same information. Member materials include but are not limited to the Welcome letter, Member Handbook or Provider Directory.

Need A Copy

Call Customer Service if you need a copy of our Handbook or Provider Directory. These copies are free. They will be sent to you within 5 business days of being asked for. You can also download a copy on our website at https://www.familydentalcareinc.com/dco-members/.

Handbook Updates

This handbook is up to date. We review and update it each year. At times changes are made to state and federal laws that effect your benefits. If this happens, we will update the handbook. When that happens, a postcard will be sent to members. It lets you know we have updated our handbook. We will advise you how an updated copy can be requested or found on our website.

Changes In Benefits

Sometimes changes are made to state and federal laws that affect your benefits. If your OHP dental benefits change, we will notify you 30 days before the change takes place. For questions about benefit changes, call Customer Service.

Yearly Postcard

We send a yearly postcard to existing members. It states you have a right to receive another Handbook and/or Provider Directory. Also, how to get them. If you do not receive a postcard, give Customer Service a call. You can also go to our website at https://www.familydentalcareinc.com/ to find these materials.

Health Risk Screening

Within 90 days (or sooner) of becoming a member, you will receive an oral health risk screening form to complete. Your answers help us get you the best dental care. You may complete the screening by mail, fax or over the phone. If you do not complete the screening and return it, we will give you a call.

We will share the information from the screening with your PCD. Getting you the right care at the right time is important. A completed screening helps us do just that. In addition, with your permission we can share (as applicable) the screening with the State, your other MCEs or providers.

If your condition changes, we will want to get an updated screening. If you are newly diagnosed as a diabetic or enter a long-term care facility are some examples. Let us know if these changes happen. Your health, including oral health can change over time. An annual update of your screening will help us keep up to date on your oral health needs.

WHAT IS THE OREGON HEALTH PLAN?

The Oregon Health Plan (OHP) pays health care costs for low-income Oregonians. The State of Oregon and federal Medicaid program pay for this program. OHP covers services such as doctor visits, hospital, dental, and mental health care. It covers addiction services related to tobacco, alcohol, and drugs. It can also help with free rides to covered health care services.

Oregon Health Plan

Family Dental Care, Inc. wants you to know how to use your OHP benefits. The Oregon Health Authority (OHA) will send you an OHP enrollment Cover letter. The letter will give you:

  • Your OHP identification (ID) number
  • Benefit package,
  • Your assigned managed care organizations (MCO).

OHA also provides each person an OHP ID card. If you did not get a letter or ID card. Or need a replacement call OHP Client Services at (800) 273-0557 (TTY) 711.

Change of Contact Info

If you move or change your phone number, you need to call:

  • OHP Customer Service at (800) 699-9075, or TTY at (800) 735-2900
  • Call Family Dental Care, Inc. Customer Service
  • Call your PCD office

Call OHP Customer Service immediately if you move out of the Family Dental Care, Inc. service area (Clackamas, Multnomah or Washington counties). You can also update your contact information online at https://one.oregon.gov/.

Managed Care Organization or Fee For Service 

OHP members may be assigned by the state to a managed care entity (MCE). Examples of MCEs are coordinated care organizations (CCOs) and dental care organizations (DCOs). When you enroll in OHP you may be able to select a CCO or DCO. If you do not select a CCO or DCO the state may choose one for you.

Some OHP members are not enrolled in a CCO or DCO for certain reasons. For these OHP members the state will be the payer. This is called ‘fee for service’ (FFS) or being on an ‘open card’.

Sometimes an OHP member may be on open card for medical but assigned to a DCO for dental. Check your OHA coverage letter or ID card to find out.

Managed Care

A CCO is a network of all types of providers in your community. The CCO network of providers works together to keep OHP members healthy. It includes providers from physical, behavioral, and dental health. CCOs focus on prevention and helping members manage chronic conditions, like diabetes.

A DCO is a managed care dental plan. Family Dental Care, Inc. is a DCO. We and our providers work together helping you, and others, to stay healthy.

Both CCOs and DCOs contract with the OHA. OHA pays CCOs and DCOs to give members the healthcare services they need.

Community Advisory Council (CAC) – CCOs have Community Advisory Council (CAC). You can find out more information about CACs by asking OHA or your CCO.

Member ID Number 

Family Dental Care, Inc. and our dentists use your OHP ID number when checking eligibility.

  • It is important to take your OHP ID card with you to your dental appointments.

OHP Member Handbook

There is also an OHP Member handbook. You can find it and/or download it online at: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/he9035.pdf. It contains more helpful information that may not be in our handbook.

Need a copy of it in an alternate format? Call OHP Customer Service at (800) 699-9075 toll-free (TTY) 711.

FAMILY DENTAL CARE, INC.

As a dental care organization (DCO) we are contracted with OHA to provide dental care to OHP members. Family Dental Care, Inc. is privately owned. It serves our members with a blended provider network. This means our network is made up of several staff affiliated clinics. Some community dental providers participate too. Our service areas include Clackamas, Multnomah, and Washington counties.

Provider Incentives

We may pay dentists in different ways to improve how you receive care and to encourage dentists to focus on improving your overall health. Members have a right to ask for information about dental payment arrangements. Dentist payments or incentives will not impact member’s access to benefits or care.

Would you like information on Family Dental Care, Inc. organizational structure? Or about provider incentives? Just call Customer Service. We will provide the information within 5 business days of the request.

Customer Service

Family Dental Care, Inc. Customer Service is here to help. They are happy to answer questions about our DCO. Please call if you have questions about:

  • Dental services that are covered.
  • How to use preventive dental services.
  • How to choose a Primary Care Dentist (PCD) or where to get services.
  • How to see a specialist.
  • How to make an appointment with a PCD.
  • Complaints, concerns, or suggestions.
  • Help getting dental care or care coordination

It is helpful to have the OHP Member ID number for the person you are calling about. Also, any other information that may help us look into your question. Call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711.

Website

Members will find helpful information on our website. It is located at: https://www.familydentalcareinc.com/

Some of the information that can be found on our website:

  • Member Handbook
  • Provider Directory
  • Dental Wellness Brochures
  • Important Forms
  • Dental Information for New & Expecting Moms
  • Lookup Tools

Practice Guidelines (Protocols)

Practice guidelines are used to create healthcare policies for dental treatment. We advise dentists to follow well accepted national dental organizations practice guidelines. This includes those of the American Dental Association and American Academy of Pediatric Dentistry. Want a copy of our practice guidelines? Call Customer Service or go to our website.

Moral And Religious Objections to Care

Family Dental Care, Inc. does not have any moral or religious objections to providing OHP covered dental services. If a dentist has a moral or religious objection to doing a dental service for you, call Customer Service. We will assist you in finding a dentist willing to provide the service.

Advance Directives

An advance directive is a form used in Oregon. It allows you to choose a person to make health care decisions for you. You might use this if you become too sick to speak for yourself. This person is called a health care representative. Federal and Oregon laws gives you the right to make decisions regarding your health care. This includes the right to accept or refuse dental or surgical treatment. Also, you have the right to form an advance directive. You can cancel your advance directive at any time.

Family Dental Care, Inc. and our providers respect these rights. Neither we nor our providers have any limitations regarding implementing these rights. Complaints concerning an advance directive may be filed with the OHA. If you would like a copy of Oregon’s current advance directive form, call Customer Service. You also can find one online at: https://www.oregon.gov/oha/PH/ABOUT/Documents/Advance-Directive.pdf.

For questions or more information contact:

Oregon Health Decisions

7451 SW Coho Court, Suite 105

Tualatin, OR 97062

Phone: (800) 422-4805 or (503) 692-0894, (TTY) 711

Email: info@oregonhealthdecisions.org

Fax: (503) 885-8758

Website: Advance Directive | Oregon Health Decisions

If you think Family Dental Care, Inc. did not follow advance directive requirements, you can complain. File a complaint by calling Customer Service at (503) 644-2663 or Toll Free at (888) 350-0996 (TTY) 711. You can also send us a letter to: Family Dental Care, Inc., 6700 SW 105th Ave., Suite 210, Beaverton, OR 97007.

You can also file a complaint with OHA:

Oregon Public Health Division

Office of Health Care Regulation & Quality Improvement

P.O. Box 14450

Portland, OR 9729

Phone: (971) 673-0540

Email: mailbox.hclc@state.or.us

Fax: (971) 673-0556

CONFIDENTIALITY POLICY

There is a law that protects your records and keeps them private. This is also called confidentiality. The law is called the Health Insurance Portability and Accountability Act (HIPAA). Family Dental Care, Inc. and our providers follow HIPAA requirements.

Your records are private. We only share your records with people who need to see them for treatment. Or for payment reasons. You can limit who sees your records. If there is someone you don’t want to see your records, please tell us in writing. You can also ask us who we have shared your records with.

We are committed to protecting your confidentiality and personal health information (PHI). Our “Notice of Privacy Practices” explains in detail how we handle our members PHI. If you would like a copy of our Notice, call Customer Service.

How To Get Copies of Your Dental Records

You have the right to request copies of your dental records. You have the right to request your record be changed or corrected if there is an error.

Your PCD has your records, you can ask them for a copy. They may charge a fee for copies. You can ask us for a copy of the records we have. We do not charge a fee for these copies. (See Member Rights)

Transfer Dental Records to Another Provider

You can have a copy of your dental record sent to another dentist. Ask the dentist who has your dental record to send them. Or ask the dentist where you want your dental record sent to request them for you. You can also call Customer Service if you need help. (See Member Rights)

MEMBER RIGHTS

As a member of Family Dental Care, Inc. you have certain rights. There are also certain things you are responsible for. If you have any questions about the rights and responsibilities listed here, contact Customer Service at (503) 644-2663 or toll free at (888) 350-0996.

You have the right to exercise your member rights without any adverse action or discrimination. If you feel like your rights have not been respected, you can file a complaint.

You can also contact an Ombudsperson through the Oregon Health Authority at (877) 642-0450 (TTY) 711. They can help you and make sure you receive good care.

We are committed to supporting your rights. Among other rights this includes your right to:

  • Availability of services
  • Adequate provider capacity and services as a DCO
  • Have us coordinate your care as applicable
  • Understand your benefits and coverage
  • Be aware of our authorization of service requirements.

As an Oregon Health Plan (OHP) member, you have the right to…

  • Be treated with dignity and respect.
  • Be treated by dentists the same way as other people seeking healthcare.
  • Choose your dentist or where you would like to get care. You can also change those choices.
  • Refer yourself directly to behavioral health or family planning services. A referral from a PCP or other dentist is not needed.
  • Have a friend, family member, or other person with you during appointments.
  • Be involved in creating your treatment plan.
  • Get information about your condition, what is covered, and what is not covered. Then you can make good decisions about treatments.
  • Accept or refuse treatments and be told what might happen based on your decision. Court ordered services cannot be refused.
  • Get a referral or second opinion if you need it at no cost to you.
  • Get written materials that tell you your rights, responsibilities, benefits, how to get services. Or what to do in an emergency.
  • Get written materials explained in a way you can understand them.
  • Learn about coordinated care organizations (CCOs) and how to use the healthcare system.
  • Get services that consider your culture and language and are in a place close to where you live. If available, you can also get care in a non-traditional setting.
  • Get care coordination, management. Or community-based care that works well with your culture and language. To help reduce the need for hospital visits.
  • Get the needed and proper services to diagnose your health condition.
  • Get person-centered care and services that give you choice, independence, and dignity. This care will meet generally accepted standards of practice.
  • Have a steady and stable relationship with a care team that will look after your overall care management.
  • Get help with using the healthcare delivery system. Find out how to get services such as: 
    • Certified or qualified healthcare interpreters.
    • Certified traditional health workers.
    • Community health workers.
    • Peer wellness specialists.
    • Doulas.
    • Personal health navigators.
  • Get covered preventive services.
  • For males and females under 18 years of age to be provided equal access to appropriate facilities and treatment. Consistent with OHA obligations under ORS 417.270.
  • Get urgent and emergency services 24 hours a day, seven days a week without prior authorization.
  • Get a referral to specialty providers for covered coordinated care services when medically needed.
  • Get help with addiction to tobacco, alcohol, and drugs without a referral.
  • Have a clinical record kept that keeps track of conditions, services received, and referrals made.
  • Have access to request, and get a copy of, your clinical record. Your dentist may charge a fee for the copy.
  • Have the right to request your record be amended or corrected.
  • Be able to transfer your dental records from one dentist to another.
  • Be provided a Member Handbook within 14 days of your enrollment.
  • Annually be advised of the right to have a copy of the Member Handbook and how to get it.
  • Given written notice your PCD is terminating participation. Notice given the later of 30 days prior to termination. Or 15 days after receipt of termination.
  • Be able to disenroll from Family Dental Care, Inc. at least annually.
  • Free to exercise your rights without it affecting the way you are treated by us or our providers. To not be discriminated against for exercising your rights.
  • If available and upon request have member information communicated electronically.
  • For Customer Service staff to be fully informed of our policies providing you and potential members dental care under OHP.
  • Make a statement of your wishes for treatment. It can tell your wishes to accept or refuse medical, surgical, or behavioral health treatment. It can give instructions and powers of attorney for your healthcare.
  • Get written notices of a denial or change in benefits before they are made. You might not get a notice if it is not required by federal or state regulations.
  • Make a complaint or file an appeal with Family Dental Care, Inc.
  • Ask for a hearing if you disagree with a decision made by Family Dental Care, Inc.
  • Get certified or qualified healthcare interpreter services.
  • Get notice of an appointment cancellation in a timely manner.
  • Not make caring for you easier for your dentists by doing any of the following:
    • Hold you down.
    • Keep you away from others.
    • Make you do something you don’t want to do.
    • Punish you for something you said or did.
  • Report abuses to Family Dental Care, Inc. and/or the OHP.
  • Get free help from the OHA ombudsperson.

MEMBER RESPONSIBILITIES

As an OHP member, you agree to…

  • Choose (or help choose) a Primary Care Dentist (PCD).
  • Treat the DCO staff, providers, and clinic staff with respect.
  • Be on time for appointments.
  • Call in advance to cancel if you are unable to keep appointments.
  • Call in advance if you expect to be late.
  • Tell your dentist what health insurance you have before your appointment.
  • Tell the staff if you were hurt in an accident.
  • Be honest with your dentists to get the best service.
  • Have yearly dental check-ups and preventive dental services to keep you healthy.
  • Get a referral from your PCD to see a specialist if you need it.
  • Use your PCD or clinic for all your dental needs except in an emergency.
  • Use urgent and emergency care appropriately.
  • Let your PCD or PCP know, within 72 hours, if you have used any emergency services.
  • Give accurate information to your dentists.
  • Help your provider get your health records. This may include signing an authorization to release your health record.
  • Participate in your own healthcare.
  • Ask questions if you are unclear about conditions, treatments and other issues related to your care.
  • Tell dentists about all your health issues.
  • Use information from your DCO, CCO, dentists, or care teams to make smart decisions about treatments.
  • Help your dentist in the creation of your treatment plan.
  • Follow directions from your dentist or ask for another choice.
  • Always bring your medical ID cards to appointments.
  • Tell OHP if:
  • You change your address.
    • You change your phone number.
    • You become pregnant or have a child.
    • Any family member moves out of the household.
    • You get or lose other health insurance.
    • You are injured by another person, entity, or have a claim for personal injury.
    • You get or lose Medicare coverage.
    • Pay for not covered services.
    • Bring issues, complaints, or grievances to our attention.
    • Read all letters from OHA and Family Dental Care, Inc. sends you. If you, are you having problems reading the information?  Call Family Dental Care, Inc. or OHP Client Services and ask for help.
    • Report Medicaid fraud. Call, email, or write us if you think you see fraud. An example would be charging for a service you didn’t get. Or if someone is using another person’s ID to get OHP benefits.

RIGHTS FOR NATIVE AMERICANS

Are you a Native American or Alaska Native? You can get your dental care from a tribal clinic dentist, even if they do not participate with our plan. Your dentist must follow the same rules as our network providers. Only covered benefits will be paid for. Some services require Family Dental Care, Inc. prior authorization. The dentist must request it before providing the service. If you need a service you dentist can’t provide, they can refer you to any dentist in our network. (See ‘Choosing a PCD’ for more information on choosing an Indian Health Care Provider)

Family Dental Care, Inc.’s Provider Network includes an Indian healthcare provider. If you would like information about this provider you can call Customer Service. You can also find information on our website at www.familydentalcareinc.com/clinics/.

RIGHTS FOR MINORS

There are times when members under age 18 (minors) may need to get health care services on their own. To learn more, read ‘Minor Rights: Access and Consent to Health Care’. This booklet talks about the types of services minors can get on their own. Also, how minor’s health care information may be shared. You can read this booklet online at OHP.Oregon.gov. Click on ‘Minor rights and access to care’ or go to https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le9541.pdf.

CARE COORDINATION UNDER OHP

CCOs bring together many types of providers, including counselors and dentists. They help to ensure providers can focus on prevention and improving your overall health. CCOs also have Patient Centered Primary Care Homes (PCPCHs). This fosters relationships with patients and providers. They can then deliver better care to the whole person.

DCOs and their providers also work with CCOs, and others to help you get the care you need. OHP wants to find ways to help you be healthy. Care coordination is your medical, dental, and behavioral providers all working together to meet this goal. You might have a Care Coordinator working with you at your CCO, as well as with us. Don’t worry we will all work together on your health care needs.

If a member is covered for medical by the state fee-for-service, we can work with the KEPRO Care Coordination Team. A member with special health care needs can reach this team directly, by calling (800) 562-4620.

For some members, their care coordination needs are complex. Intensive Care Coordination (ICC) is a service that supports members with more complex needs. Family Dental Care, Inc. does not provide ICC services, however we work with others such as your CCO or the state that do.

Even though your different health care providers are trying to work together, it can be confusing to you. We want you to know any member can ask for our help to navigate the coordinated care system. In fact, a family member or caretaker can ask for help on your behalf. Call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711 to ask for this help. If you need additional help, ask to speak to our Care Coordinator.

Family Dental Care, Inc. Care Coordination

Family Dental Care, Inc. wants you to get the care you need to stay healthy. All members have access to Care Coordination services. Call Customer Service for help getting the dental care you need and information on how to use your benefits. We will:

We are here to help coordinate your dental care with your providers, community support and social service agencies. Our staff can even help coordinate your dental care for a service that is not covered by OHP. Call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711 to ask for this help. Once these services are started you will be assigned a Care Coordinator and you will receive their contact information. If you need any help regarding your case, please reach out directly to your Care Coordinator. They will be the best person to help you with general questions or concerns moving forward.

Dental Care Coordinator

All Customer Service staff can help members with their dental needs. Some members may need extra care coordination. If you need extra help let us know. Members needing extra help are assigned to our Care Coordinator. You or someone on your behalf can request assistance from our Care Coordinator by calling Customer Service. Or an email can be sent to quality@familydentalcareinc.com. Our staff will work with you, and others to get you the dental care you need. This includes coordinating your dental care with your providers, other MCEs, as well as community support and social agencies.

Professional standards state that dental providers are responsible for maintaining and sharing a patient’s electronic health record (EHR). Family Dental Care, Inc. is not a provider of services. We require all our providers to share their patient records as necessary. Sometimes it can be difficult getting your EHR from your provider. Or getting your provider to send your EHR to another provider. If a member needs our help requesting their EHR, call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711.

Our Care Coordinator will help to ensure you have an ongoing source of dental care appropriate to your needs. For high-risk members this is very important. In most cases, for dental treatment this source will be your PCD. We will want to help you get connected to a PCD.

Some examples of members who may need extra care coordination are:

For other than dental treatment, our Care Coordinator is the designated person for coordinating your care plan. We will work with you to provide you with timely dental care. This includes for emergencies or urgent dental needs (such as a toothache) as well as regular dental care (like a teeth cleaning).

Care coordination goes beyond dental treatment. Your PCD and our Care Coordinator both have roles getting you the best care possible. We want you to have a dental treatment plan ‘and’ a care plan appropriate to your needs. Examples of care plan activities: Helping your PCD and physician get connected. Helping you arrange for a driver if one is needed after dental surgery. Care coordination is always member focused. The dental care plan is developed with help from you, your family and/or caretaker.

Our Care Coordinator can help high-risk members with a transition of care. This can be when a member changes PCD. Or when a member changes from one dental plan to another. Or even from fee-for-service to our dental plan (See ‘Care While You Change Plans’). Our coordinator will work with the previous PCD and/or dental plan regarding the transition of care. A member may still be receiving dental services from the previous PCD and/or plan. If so, our coordinator will work to ensure needed services are continued in our plan. They will refer you to a qualified provider in our network. By providing care coordinating for a transition of care, we can help prevent duplication of services and activities. This can include honoring (with written documentation) of ongoing covered dental services being prior authorized.

Just call Customer Service to ask for this help.

Special Health Care Needs

Members who have special health care needs may need and benefit from care coordination. (Examples: members receiving long term services and support, or those with chronic or special health care needs.) If you have special health needs call Customer Service. They can help you:

You, your family, or a caretaker may request special health care needs care coordination. Call Customer Service to ask for this help.

Care While You Change Plans

Some members who change DCOs can still get the same services and see the same dentists. This means care will not change when you switch your DCO or move to/from OHP FFS. If you have serious health issues, your new and old plans must work together. They will do so to make sure you get the care and services you need.

Who can get the same care while changing plans? A member who needs transition care that has serious health issues and/or is at risk of hospitalization. One who may be receiving continued care which if it is stopped could harm your health. If you have a serious health issue and need care while changing plans call Family Dental Care, Inc.

If you were receiving dental services before changing dental plans and need to continue them, we can help. We will work to get you the dental service you need to continue receiving. This includes referring you to a qualified provider. Call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711 for more information. Or visit Family Dental Care, Inc. to learn more about this special type of continued care. Our ‘Transitions of Care Policy and Procedures’ can be found at this link https://www.familydentalcareinc.com/dco-members/.

(See Getting Care When You Change Dental Plans. Also, Who Can Get the Same Care While Changing Dental Plans.)

CULTURAL SENSITIVITY

Family Dental Care, Inc. and our providers respect the dignity and diversity of our members. As well as the communities where they live. We want to serve the needs of all our members. We want all members to feel welcome and well cared for.

Your access to providers and services that are culturally appropriate and meet your language needs is important. Our provider directory shows if a dentist has had cultural competency training. It also notes whether a dentist speaks another language.

Dental Health Education

We have dental health education materials that can be sent to you. They cover home care, prevention, and dental disease management. These materials are available in other languages besides English. We have selected materials to share with members that are culturally sensitive.

Call Customer Service for more information. Some of these learning materials are available on our website https://www.familydentalcareinc.com.

ADEQUATE PROVIDER NETWORK

Our goal is to have an adequate provider network for members. One that supports access to care as close as possible to where they live or seek services. In an urban (city) area that means within 30 miles or 30 minutes travel time. For a rural area within 60 miles or 60 minutes. Call Customer Service if you have a concern about our network not being adequate.

This includes being able to provide reasonable dental care accessibility for members with physical or mental disabilities. If we do not have a provider in our network to meet your special dental health care needs, let us know. As dentally appropriate, we can consider looking outside our network for a provider to meet your needs.

Family Dental Care, Inc. wants you to have access to services and support that meets your cultural and language needs. We want these services available as close to where you live or where you seek care as possible. If you need help choosing a dentist who meets your cultural and language needs call Customer Service.

Timely Access to Care

We want to provide timely access to care based on your dental needs. Family Dental Care, Inc. providers have the same office hours for our members that they do for their other patients. For emergency care you should be seen within 24 hours. For urgent care you should be seen within 2 weeks, or as soon as needed. For routine care you should be seen in an average of eight (8) weeks, and no more than twelve (12) weeks. Please be aware, sometimes there is a clinical reason for it to take longer.

Family Dental Care, Inc. works hard to ensure that we have providers who are both close to you, and who can meet these timeframes. Our providers are spread out around our service area. This means our members are better able to get to their dental clinic and to get the dental care they need when they need it.

Priority Access to Care

Certain members with special needs may need priority access to care. An example of this is pregnant women. Delay could risk harm to their health or to their unborn baby.

For this reason, pregnant women should be seen within:

Another example is members with special health care needs, like someone who has been in an accident or needs surgery. Or those receiving long term services and supports. These members may not be able to wait to be seen. If you are a member who needs priority access to care let Customer Service know.

Notification Of Changes Affecting Member Access to Care

A change in our provider network could affect member access to care. (Example: a participating provider clinic closes, or the clinic decides to no longer contract with our plan.) If a significant change takes place in our network, we will notify affected members. Notice will be given at least 30-days before the change. If the dentist has made this change without notice, we will tell members as soon as possible, and within 15 days of notice from the provider. Letters will be sent to members who had the provider as their PCD or were seen by them on a regular basis.

The notice we provide to members will be translated if our information shows a language other than English as your primary. If you or someone helping you needs the notice translated call Customer Service.

Family Dental Care, Inc. will work with affected members to get you the dental care needed. This includes helping members transition to another participating dentist. If you have questions or need help, call Customer Service at (503) 644-2663, or toll free at (888) 350-0996 (TTY) 711.

Provider Directory

We can send you a Provider Directory. A copy will be provided within 5 business days of the request. It can also be found online on our website https://www.familydentalcareinc.com. There is a city search feature. Enter a city and locate providers near that city. The directory includes other information a member may need in selecting a PCD. Like languages spoken other than English. Clinic features too.

CHOOSING A PRIMARY CARE DENTIST (PCD)

You may choose a PCD from the provider directory. Most are open to seeing new patients. Please choose your PCD as soon as you can. Families can have the same or different PCDs. Whatever they want. Once a member sees a clinic or dentist, they become the PCD. They will be responsible for your overall dental health. Do not wait until a dental emergency to make an appointment with your PCD.

For the most part, you must choose an in-network dental provider as your PCD. You have the right to choose a PCD. This is called your “freedom of choice”. Our network is comprised of dental providers that we work with to deliver care. You also have the right to change your choices. Please choose a PCD from Family Dental Care, Inc. Provider Directory. If you need help choosing a PCD, call us.

If we cannot find you a provider in our provider network for dental services, we will help you find another provider that is not in our network. Remember to check with us first before you use a provider that is not in our provider network. If you have questions, please call Customer Service at (503) 644-2663.

You will find a listing of our network providers in our ‘Provider Directory’. The provider list will tell you if a provider is taking new patients. Our directory can be found on the Family Dental Care, Inc. website at https://www.familydentalcareinc.com/clinics/. For a printed copy call Customer Service. We can also provide a copy in other formats such as large print or another language.

If Native American or Alaska Native, you can choose an Indian Health Care Provider as your PCD if:

(1) The dentist participates with Family Dental Care, Inc. as part of our network; or

(2) The dentist is not a part of our network but you are otherwise eligible to receive services from them; and

(3) The dentist has capacity to be your PCD.

If you do not choose a PCD within the first month, we will send you a letter. It will direct you to one of our dentists near your home address. They will become your PCD. You may change PCDs by contacting Customer Service.

Having a good relationship with your PCD is important. They will work with you to take care of your dental needs. Your PCD will:

  • Provide all your routine and primary dental care.
  • Arrange for specialty care when needed.
  • Write prescriptions (only for dental care needs).
  • Keep your dental records.
  • Submit requests for prior authorizations.
  • Work with your CCO, other health plans, or providers (as applicable).

GETTING CARE

HOW TO MAKE A DENTAL APPOINTMENT 

Call your PCD during office hours. If you need your PCD’s number, check the provider directory or call Customer Service.

  • Tell the office you are a Family Dental Care, Inc. member and why you need to see a dentist.
  • If possible, give them a phone number where you can be reached.
  • Remember to take your OHP ID card with you to your dental visit.

If You Cannot Keep Your Appointment

Call your dental clinic as soon as you can. Tell them you need to cancel and if you would like to reschedule. Call at least 24 hours before a scheduled dental visit. Failure to cancel means the dental clinic will not be able to help someone else. Some clinics may dismiss a patient if they miss a dental visit.

Access To Emergency Care

Emergency dental care is available. We cover OHP dental services to stabilize (to keep from getting worse) your emergency. For example, emergency services to relieve pain and infection. You can use it 7 days a week, 24 hours a day. Emergency dental care does not require prior authorization. If you need emergency dental care and do not have a PCD call Customer Service at (503) 644-2663. We can help you get the dental care you need.

Your CCO or OHA covers hospital and medical services. Including emergency room and doctor visits. Once you are stable follow-up with your PCD. They can take care of any dental care you may need. (See Emergency Dental Care section for more information.)

After Hours Care 

Dentists are available day and night, even on weekends and holidays. If you need emergency dental care in the evenings or on the weekend, call your PCD. Each dental clinic has a way to reach your dentist. Identify yourself as a patient and Family Dental Care, Inc. member. Your PCD will call you back within 30 or 60 minutes depending on the urgency of your need. Your PCD will decide the best course of action.

If you ‘do not’ have a PCD call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711. If someone is helping you like a representative or a long-term care provider, they can call for you. We are available to assess your urgent and emergency dental care needs and will call back within 30 or 60 minutes depending on the urgency of your need.

We do not require prior approval for covered OHP emergency, or urgent dental care needed to stabilize (to keep from getting worse) pain and/or infection. If unable to reach your PCD or us, we will consider payment to an out-of-network provider. (See Member Handbook section on Out-of-Network Dental Care for more information). As your dental plan, we want you to be able to get emergency or urgent dental care needed to relieve your pain and/or infection.  

Please use the after-hours call-in system for emergency and urgent care needs. If you need routine dental care or general information, Customer Service is available Monday through Friday 9AM to 5PM. You can also send us an email at quality@familydentalcareinc.com.

CHANGING YOUR PRIMARY CARE DENTIST

If you need to change your PCD use our provider directory or website at https://www.familydentalcareinc.com/clinics/. The same process as when choosing a PCD initially can be used again.

We feel a relationship with your PCD is key. We discourage a member from changing PCD more than once in a year. If a member wants to change their PCD and it has been less than a year, call Customer Service. Let them know your reason for the change, and it will be reviewed by our dental director. If appropriate an exception will be approved.

Several in network providers practice in clinics with more than one provider. A member who wishes to change PCD may be able to do so without needing to go to another clinic.

  • If a dentist leaves our network, we will notify you of the change 30 days before it happens. If we are not able to, we will notify you of the change as soon as possible.

WHAT TO DO IF YOU ARE NEW TO FAMILY DENTAL CARE, INC.

1. Choose a Primary Care Dentist (PCD).

2. Make an appointment with your PCD within your first 30 days.

If you can’t get in to see your PCD during your first 30 days and need services call us. This includes members becoming newly enrolled in Medicaid. We are here to help with your transition to our dental plan.

Do you need a prescription or dental services right away?Were you receiving ongoing dental services from a previous plan or dentist that need to continue? Care coordination is available. We can help you get needed dental services including during your first 30 days. Call Customer Service at (503) 644-2663, or toll free at (888) 350-0996 (TTY) 711.

Dental Care Needs Before You Have a Primary Care Dentist

A member might need dental services right away. Sometimes this is in the first 30 days of being assigned. Or sometimes it may be after that time. If you haven’t chosen or seen a PCD yet and need care right away call Customer Service. They can provide care coordination to help you get the dental services needed.

Getting Care When You Change Dental Plans

Some members who change OHP dental plans can still get the same services and see the same dentists. That means care will not change when you switch dental plans or move to or from OHP fee-for-service. If you dentist is not part of our network, we can help by referring you to a qualified provider who is. If you have serious health issues, your new and old plans will work together to be sure you get needed services. (See Care While You Change Plans)

Who Can Get the Same Care While Changing Dental Plans?

This help is for members who have serious health issues, need hospital care, or inpatient mental health care. If you need care or help while you change dental plans, please call Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711. (See Care While You Change Plans)

OUT OF NETWORK DENTAL CARE

In most cases, you must see Family Dental Care, Inc. network providers. A dentist who is not in our network is called non-participating. Sometimes a network provider is not able or available to meet your needs. When this happens, we can arrange for you to see an out of network provider. This will be at no cost to you. Customer Service will work with you or your PCD to meet your dental needs.

Generally, you will need our approval if you see a dentist out of network. Customer Service will work with a non-participating dentist to get the dentist’s agreement to accept our fees. We will also confirm that the dentist is willing to follow OHP rules important to your care. Let us know if you need services from a non-participating provider. You, someone helping you, or your PCD can call Customer Service.

While You Are Away

While you are outside our service area, Family Dental Care, Inc. will cover emergency care (see Emergency Dental Care). We cover OHP dental services to stabilize your emergency. For example, emergency services to relieve pain and infection. We also cover post emergency services to maintain your condition and keep it from getting worse. If you have emergency dental care while away when you return contact your PCD. They will want to see you to determine if further treatment is needed.

If you are away and need emergency dental care call Customer Service. They can help you find a dentist near you willing to accept OHP. Have you already seen a dentist? They can try and work out payment arrangements. Let us know if you have seen a provider for a dental emergency while away. The sooner the better.

To be paid under OHP, a provider must meet certain requirements. Unfortunately, not all out of the service area providers do. Some are unwilling or unable to do so. We will try our best to work together with them.

While OHP covers emergency care anywhere within the United States (US) members should be aware of what can happen. Even if we approve emergency service(s) to a provider, the provider might not be willing to bill us. You could receive a bill for these services. Do not ignore a bill from a provider who has treated you for an emergency. If you get a bill let Customer Service know. They will help try and resolve the issue. If the billing cannot be resolved you can make a complaint. You have a right to ask for the decision to be changed. This can be done through an appeal and a state fair hearing. (See Appeals and Hearings)

As soon as you get a bill for a service that you received while you were on OHP, you should:

  1. Call OHP member services right away and explain that a provider is billing you for an OHP service. We will help you get the bill cleared up. Do not wait until you get more bills.
  2. If applicable, you can appeal by sending OHP a letter saying that you disagree with the bill because you were on OHP at the time of the service. Keep a copy of the letter for your records.
  3. Follow up to make sure we paid the bill.
  4. If you receive court papers, call us right away. You may also call an attorney or the Public Benefits Hotline at (800) 520-5292 for legal advice and help.

There are consumer laws that can help you when you are wrongfully billed while on OHP.

To avoid billing issues: Be sure to have your OHP ID card with you when traveling. Present it to the dentist and ask if they are willing to bill Medicaid. Contact us as soon as possible, preferably while you are at the dentist’s office. Do not sign any billing paperwork until the dentist has agreed to bill Medicaid. These steps are not always possible in an emergency, but if taken they can help prevent future billing issues.

OHP covers emergency care in the US at no cost to you. However, emergency care outside the US is not covered. This means OHP will not pay for any care you get in Mexico or Canada.

SPECIALISTS

Your PCD at times may need to refer you to another dentist for a service. It may be a general dentist with more experience in doing a service. It may be a specialist. Your PCD will handle the paperwork involved with a referral on your behalf.

Your PCD and/or referral provider may need to ask us to approve the service requested. This is part of the process. The first visit with a specialist (unless an emergency) is often a consultation. This means another provider will do an exam and decide what treatment is needed. Afterwards the referral provider may not feel the service requested is the right care. They may provide a different treatment plan. You will be informed all along the referral process of our decisions. This includes providing you a Notice of Adverse Benefit Determination (denial letter) should we deny the service requested.

Upon approval of a referral request, we will notify the specialist. The specialist’s office will call you to set up a visit. In addition, we will send you notification too. It will be an approval letter with the referral provider’s name and contact information.

Generally, referral providers will be in our network. There can be exceptions due to a member’s special needs. Sometimes the difficulty of a service may require us to go out of network.

If you need to see a specialist or other provider, your PCD will refer you. However, you can see specialists for some kinds of care without seeing your PCD first. This is called “direct access to a specialist”. Some special needs members may need direct access to a specialist. Special health care needs sometimes require long-term services and support. When this happens, you may need direct access to care from a dental specialist. Call Customer Service if you see a specialist without a referral.

Sometimes Family Dental Care, Inc. approves a standing or long-term referral to a specialist. If you have special needs, as appropriate, we may approve you to continue to see a specialist over a period-of-time. Call Customer Service for more information.

  • Most referral providers will want to do their own exam and diagnosis.
  • Native American or Alaska Native members who are being seen at a tribal clinic can be referred to specialty services by their tribal dental provider.

Second Opinions

Family Dental Care, Inc. covers second opinions at no cost to you. If you or your PCD wants a second opinion, call Customer Service. For a second opinion you will be directed to a dentist in our network. However, if you want to see a dentist outside our network let us know. Generally, you will need OHP dental approval to do so.

DENTAL COVERAGE

As your dental plan we are responsible to pay for all covered OHP dental services on the Prioritized List of Health Services. Services must be dentally appropriate.

OHP covers dental care. Dental benefits are for members of all ages. Seeing a dentist can lead to better overall health. A healthy mouth can keep your heart healthy. It can improve your diabetes. Dental care is important for everyone, but especially for a pregnant woman.

Dental disease is almost 100% preventable. Home care, regular check-ups and cleanings can keep your mouth healthy. Young children should start seeing a dentist early to enjoy a cavity free mouth. Dental sealants are a plastic coating painted on chewing surface of a back tooth. They are a great cavity prevention service for young members.

  • Covered services need to be dentally appropriate. They should have an expected good outcome. Be cost effective. Even if a dental service is covered by OHP, it may not be the right option for you.

The Prioritized List

OHP does not cover all conditions and treatments. OHP uses a list to determine what health care services are covered. It is called the “Prioritized List of Health Services”. It is for medical and dental services. The list can be found online at https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx.

The Health Evidence Review Commission (HERC) ranks conditions and treatment pairs in order of being effective. The list ranks treatment to prevent illness or keep it from getting worse higher on the list. The Oregon legislature decides which line on the list funding is through. Funding decisions are based on whether a service is above or below the funding line.

  • Family Dental Care, Inc. (FDCi) pays for all services approved on the Prioritized List. You cannot be charged for any service covered by FDCi.

Dental Services That OHP Covers:

Dental BenefitsLimits to Care
Exams, X-rays, cleanings, Fluoride treatments Covered for all members. Some age limitations. No prior authorization required.
Basic restorative care – FillingsCovered for all members. Some age limitations for certain services. No prior authorization required.
Stainless steel crownChildren – no limit. Adults – some limits. No prior authorization required.
Complete and Partial DenturesCovered for all members. Some age limitations for certain services. Frequency limits apply. Call for details. Prior authorization required.
SealantsCovered every 5 years for children (16 and under) with permanent molars. No prior authorization required.
Permanent Crowns Covered for all members. Some age limitations. Some limits to teeth covered. Prior authorization required. Call for details.
Extractions (removing teeth)The teeth must have symptoms beyond normal pain. Wisdom teeth and complex extractions require prior authorization. Extractions for orthodontic care are not covered.
Root Canal TherapyCovered for all members. Some age limitations. Some limits to teeth covered. Prior authorization required. Call for details.
Periodontal (gum care)Covered for all members, some limits apply. Benefits may vary based on other member conditions. No prior authorization required.
Orthodontia (braces)Age limits. Must have cleft palate, cleft lip, or diagnosis of certain facial deformities diagnosis. Prior authorization required.
Emergency and Urgent Care Covered for all members. No prior authorization required.
Type of Dental Service(s):Dental Plan Coverage:Medical Plan Coverage:
Dental ServicesCovered when you see your dentist or dental hygienist Covered when you see your doctor or nurse
Scheduled dental services in a hospital or surgery centerCovered for dental services by your dentist Covered for doctors, nurses, hospitals, and surgery centers
Hospital visits for a dental problem Not coveredCovered
Prescription for a dental visit or problem Not coveredMust be ordered by your dentist. Covered by CCO or State. Must be on CCO or State formulary.
Over the counter medicationNot covered by the dental plan.Over the counter medication

Above we have listed some OHP dental services that are covered, but not all. For more information on covered services call Customer Service.

OHP covers dental services that are expected to have a good outcome. Treatment needs to be practical and dentally appropriate. Procedures need to be cost effective.

TELEDENTISTRY

It is possible to providesome dental services using teledentistry. (Examples: a dentist visit to triage a toothache, or nutritional counseling.) OHP covers teledentistry.

Teledentistry can include the following:

  • Visit with a dentist using audiovisual technology. (Examples: Zoom, Facetime, Google Hangout, Teams.)
  • Visit with a dentist using audio. (Example: phone call between dentist and patient.)
  • Sometimes dental information will be collected at one place and sent to a dentist somewhere else. (Example: hygienist sees you in a dental van and sends x-rays to dentist at nearby clinic.)
  • A dentist may review information without you being present in real time and get back to you with findings.
  • Patients and dental providers can be connected by using cell phones, tablet computers, or personal digital assistants.

Some dental providers use teledentistry and others are not doing so. You can find providers who offer this service in our Provider Directory. You can also, call Customer Service to find out. If your PCD does offer teledentistry, it is up to you whether to receive services this way. Dentists are prohibited from limiting you to this way of delivering a service. We want to ensure your visit is purposeful as well as culturally and linguistically appropriate. If you would like an interpreter during this visit one can be arranged. The provider can request an interpreter, or you can call Customer Service.

What Will You Need?

For a teledentistry visit you will need either a computer, laptop, tablet, or smart phone. The device you use will need to support video and/or sound depending on how the visit will take place. Different dentists use different types of teledentistry services. If you have questions about the visit or need support, call the provider. Some providers may be willing to do a test visit before your actual scheduled visit.

Many dental services will need you to visit your PCD clinic. Services like comprehensive exams, x-rays or some hygiene appointments cannot be done through teledentistry.

Teledentistry is secure. Your protected health information is protected just as if you had a face-to-face visit. If you have any questions about teledentistry give your PCD a call or Customer Service at (503) 644-2663, or toll free at (888) 350-0996 (TTY) 711.

EMERGENCY DENTAL CARE

Dental Emergency: a dental emergency is when you need same-day dental care. Emergencies include a severe toothache or gum swelling. Other examples are an infection in your gums or teeth. Or a tooth that has been knocked out.

Family Dental Care, Inc. accepts the “prudent layperson” definition of a dental emergency. If something happens that an average person believes is a dental emergency, then it is. It is available 24 hours a day and 7 days a week. We cover emergency dental care.

For a dental emergency, please call your PCD. Network dental providers will see a dental emergency within 24 hours. A member may need to wait to be worked into the schedule. Some offices have emergency walk-in times. If you cannot reach your PCD or you do not have one, call Customer Service. They will help you find emergency dental care. If none of these options work for you then you may call 911 or go to the ER. Dental emergencies rarely need this last option.

We cover emergency dental care provided in a dental office. Should you have a dental emergency, and our network dentists are unable to see you. We will consider payment for emergency dental care, even if the provider is out of network. After you receive emergency care call your PCD. They will want to arrange for more care if you need it.

If you see an out of network provider, let us know as soon as possible. We may be able to cover the service. The service will need to be an OHP covered benefit. An out of network provider will need to meet OHP credentialing and be willing to accept our fees.

Your CCO or OHA covers hospital and medical services, including emergency room and doctor visits. If a dental condition becomes a medical emergency, follow your CCO or OHA’s information on emergency services.

Post Emergency Care

Emergency care is covered until you are stable. Follow-up care to maintain, improve, or resolve your condition once stable is also covered. This is called post-stabilization care. It is available 24 hours a day and 7 days a week. We cover post stabilization care.

What should a member do if we cannot be reached? Or we do not respond to a prior authorization request for post emergency care? We want you to get the dental care needed to remain stable. No prior approval is needed in this situation for us to consider payment.

What if you are unable to obtain post stabilization services in network? You might be traveling? Or due to weather a network provider cannot see you. We will consider payment for post stabilization care even if the provider is out of network. After you receive post emergency care call your PCD. They will want to arrange for more care if you need it.

If you see an out of network provider, let us know as soon as possible. We may be able to cover services. The service will need to be a covered OHP benefit. Also, the out of network provider will need to meet OHP credentialing and willing to accept our fees.

Urgent Dental Care

Urgent dental care: when you need dental care soon, but not immediate treatment. Examples of urgent dental care are a toothache, swollen gums, or a lost filling. For urgent dental care call your PCD. If you cannot reach your PCD or you do not have one, call Customer Service. They will help you find urgent dental care.

  • Dental urgent care is best treated in a dental clinic. The emergency room may not have the right skills or tools to help you.
  • We cover OHP urgent dental care services to relieve your toothache, swollen gums, or a lost filling.
  • You do not need a Prior Authorization (approval) for urgent care services to relieve pain and/or infection.
  • We also cover services to maintain your condition and keep it from getting worse.
  • While urgent care services do not require prior approval, some post stabilization services may require approval. For example: the dental service to relieve your pain prior to a root canal does not require approval. However, the root canal service itself would require approval.

OHP BILLING AND COVERED/NONCOVERED BENEFITS

OHP covers many types of dental services, but not all are covered (see Dental Coverage). If you want a dental service that is not covered talk to your PCD. There may be a covered service that could work in its place.

Sometimes, a dentist doesn’t do the billing paperwork (claim) correctly. If so and the provider doesn’t get paid for that reason, that doesn’t mean you have to pay. You may receive a service that we refuse to pay for the dentist. The dentist should not bill you. When we deny a claim from your dentist, you will get a denial letter. The denial notice does not mean you have to pay. The dentist will need to write-off the unpaid charges.

When A Member CANNOT Be Billed

  • OHP does not cover missed appointment charges. A provider should not bill you for a missed appointment.
  • If a service is denied due to a provider error such as the provider did not check if you were eligible on the date of service, you cannot be billed. Or if the provider did not get prior authorization when required, you cannot be billed.
  • If we deny a claim or service, you or the provider with your permission have appeal rights. If we deny a claim or service, even though you cannot be billed you may decide to file an appeal. You can find more information on how to file an appeal in that section of the handbook.
  • OHP does not allow members to be balanced billed by a provider. This applies to both In-Network and Out-of-Network providers. A provider must accept our payment for a covered service, as payment in full. The provider cannot bill a member the difference between what the provider billed, and we paid.

When A Member CAN Be Billed

There are only a few situations, that OHP allows a member to be billed.

  • If the service is not covered, you can decide to pay. The dentist will need to have you sign a form. It is called the “Agreement to Pay Form” (OHP 3165 or OHP 3166).
  • For the provider to bill you for a not covered service, you must be asked to sign this form before the service is performed.

Do you have questions about not covered services? Or a question about why you are being billed?  Call Customer Service at (503) 644-2663, toll free (888) 350-0996, and we will be happy to help you.

There should not be any surprises regarding billing. If a provider bills a member, the provider must inform you before you get the service. You should be told what the service is that is not covered, and how much it will cost. This information should be provided at the time you are signing the Agreement to Pay Form. You should receive the service within 30-days of signing the agreement, and the provider cannot change the fees once you sign.

What To Do if You Get a Bill

If you get a bill don’t ignore it and call Customer Service right away. Many providers send unpaid bills to collection agencies. It is harder to fix the problem once that happens.

Providers can only send a bill to collections in certain cases. Customer Service we will work with you to make sure you are not at risk. They can talk you through all the options, and even talk to the provider for you.

PRIOR AUTHORIZATION (PRE-APPROVAL)

Some dental services your dentist requests may need a prior authorization (PA). A prior authorization is advanced approval before you get the service. Some examples of services that need a PA, such as: dentures, root canals, and non-emergency complicated extractions.

Your dentist will submit a PA to us for you. If you want to know if a service needs a PA or its status, call Customer Service.

Some emergency or urgent dental services do not need a PA. In these cases, your dentist or specialist will decide if it is too important to wait for a PA. They will perform the dental procedure and then let us know after. For example: the dental service to relieve your pain prior to a root canal does not require approval. However, the root canal service itself would require approval.

OTHER IMPORTANT INFORMATION

CHANGING YOUR DCO

At certain times you can change your DCO if another is available. For most members they can change:

  • If new to OHP during the first 90 days.

During the first 30 days after being enrolled in a DCO.

  • When renewing OHP coverage.
  • After being enrolled in a DCO for 6 months.
  • For any other reason one time a year.
  • If moving to a place your current DCO does not serve.

To change your DCO, you will need to contact the OHA to do so.

The following members are not subject to the same open timeframes to change their DCO. They can change or leave their DCO at any time. They are:

  • American Indian and Alaskan Native.
  • Medicare members (but must have a DCO for dental).
  • OHP members can choose OHP FFS rather than a DCO if they have an important OHP-approved medical reason. First the member should call the DCO for help. If the DCO cannot help, call OHP client services at (800) 273-0557.

DISENROLLMENT 

A member, or someone who represents the member, can ask to be disenrolled from the DCO. This can be done verbally or in writing. This request can be made directly to the state (or its agent). The effective date of the disenrollment will be the first of the month after OHA’s approval of the request.

Reasons a member can request disenrollment without cause are:

  • A member may request within 30 days of an error by OHA.
  • During the 90 days after OHA initial enrollment of the member into a DCO.
  • Within 90 days after OHA sends a member notice of enrollment into a DCO.
  • Once every 12 months thereafter or OHP renewal.
  • After 6 months of being enrolled in a DCO.
  • FBDE members and American Native/Alaskan Native may change DCO, or disenroll to fee-for-service, at any time.
  • Member has one additional chance if none of the above apply.

Reasons a member can request disenrollment with cause are:

  • Due to moral or religious objections the DCO does not cover a service the member seeks.
  • The member needs services the DCO is unable to provide.
  • Other reasons like poor quality of care or lack of access to providers, such as:
    • The member moves out of the service area;
    • Services are not provided in the member’s preferred language;
    • Services are not provided in a culturally appropriate manner;
    • The member’s health requires a change; or
    • To ensure continuity of care.

Examples of reasons a DCO can ask for disenrollment of a member:

  • Member is abusive or threatening to DCO staff, a provider or other members.
  • Member is uncooperative or disruptive, except when such behavior is due to member’s special health care needs.
  • Member commits fraud, such as letting someone use his/her OHP ID card.
  • Other member-specific situations with OHA approval.

For questions on disenrollment call OHP client services at (800) 273-0557 or (800) 699-9075.

Family Dental Care, Inc. will only request you be disenrolled for reasons OHP allows.

  1. You move out of our service area.
  2. Credible information leads us to believe you have taken part in fraud. An example, giving your OHP ID to another person to use.
  3. A police report is filed that you have been physically abusive to your PCD or staff.

Family Dental Care, Inc. will not request you be disenrolled due to such things as:

  1. Your health gets worse.
  2. You needed a lot of services.
  3. You have a disability.
  4. Your disruptive behavior resulting from special needs.

What Happens if OHA Approves the Request for Disenrollment?

Once OHA approves a request to be disenrolled they will reassign you to a new DCO. You will get a notice in the mail telling you about the switch. The letter will include information on your new DCO and how to request a hearing if you don’t agree with it, or how to file a complaint.

Other Information

Members will receive a letter with disenrollment rights at least 60 days before the start of each enrollment period.

If you move to a new area call OHP client services as soon as you can to let them know.

For more information, or if you have questions on disenrollment call Customer Service at (503) 644-2663 or OHP Client Services at either (800) 273-0557 or (800) 699-9075.

NON-EMERGENCY TRANSPORTATION

If you have no way to get to a covered dental appointment OHP may help you. OHP pays for rides to health care that OHP covers. This benefit is called non-emergency transportation. There is no cost to you for this service. Travel can be by bus, local ride share, or even help you pay for gas if using your car. This help may require pre-approval. Money you get for these services is paid for by your CCO or the transportation brokerage. Call your CCO or local service for more information or to ask for a ride. The numbers to call:

  • Health Share – Ride to Care (855) 321-4899
  • Trillium – MTM (877) 583-1552
  • All other OHP members: Tri-county MedLink (866) 336-2906

For more information on local ride services, call your CCO. Or go to OHP.Oregon.gov then (click) ‘Rides to Appointments’. You may also call Family Dental Care, Inc. for assistance in arranging a ride.

OHP Non-Emergency Medical Transportation Map link: Oregon Medicaid Non-Emergent Medical Transportation Brokerage Information

THIRD PARTY LIABILITY

If a member has ‘other’ dental insurance or an accident/injury covered by other insurance. Members are required to provide a clinic or DCO with this information. At a minimum this includes:

Copayments and Buy-Ups

Our members do not pay anything out of pocket for OHP covered dental services. Our network clinics do not collect co-payments.

Buy-ups are not allowed under OHP. A buy-up is when you are charged the difference between a covered service and a not covered service.

If you are asked to pay for a service or get a bill, call Customer Service at (503) 644-2663, or toll free at (888) 350-0996 (TTY) 711. There are very few situations in which a dentist can bill an OHP member.

When You Might Have to Pay

  • You may have to pay for services if you see a dentist that does not take OHP.
  • You may have to pay for services if you weren’t eligible for OHP when you received the service.
  • You will have to pay for services not covered by OHP. A detailed Agreement to Pay should list the services that will be provided and their cost to you.

QUITTING TOBACCO

US Centers for Disease Control and Prevention report smoking is the leading cause of preventable death and disease. Smokers are more likely to develop heart disease, stroke, and lung cancer. Whether you smoke cigarettes, cigars, or smokeless tobacco there is a health risk. This includes risks that affect your oral health like gum disease and tooth loss.

Nicotine dependence occurs when you need nicotine and find it hard to quit using it. It produces pleasing effects in your brain, but these effects are temporary. Regardless of how long you have used tobacco stopping can improve your health. You can break your dependence on nicotine. Many effective treatments are available. Ask your dental provider for help.

OHP covers your dental provider helping you to quit using tobacco. These services are free to Family Dental Care, Inc. members. If you need help quitting tobacco, talk to your dental provider. No referral is needed.

Your CCO or OHA may cover smoking cessation counseling, nicotine gum, patches, and/or medications.

You can also call toll free at (800) QUIT-NOW, or (800) 784-8669 to be connected to Oregon’s quit-line. Or go to https://www.quitnow.net/mve/quitnow?qnclient=oregon.

MENTAL HEALTH INFORMATION

Dental anxiety can sometimes keep a member from seeking dental care needed. Your PCD, medical provider, and/or mental health provider can help. They can give you tips on ways to lower anxiety for children and adults. Our website has tips in our blog section at https://www.familydentalcareinc.com. Members who have used these tips have been able to overcome dental anxiety. Let your PCD know if you have dental anxiety.

Declaration for Mental Health – This form tells what kind of care you want if you cannot make decisions. More information on the ‘Declaration of Mental Health Treatment’ is in the OHP Member Handbook. You can also talk to your primary care (medical) provider about it.

PRESCRIPTIONS

Family Dental Care, Inc. pays for drugs your PCD uses while you are at the dental office. Example, member with gum disease is given a prescription rinse to use while in the office. This may be covered. We do not pay for every drug used in the dental office. Example, member is given Tylenol while at the office. This would not be covered. It is not standard for a dentist to bill for this type of drug.

Over-the-counter drugs, even if given while at the dental office are not covered by us. Your CCO or OHA may cover some over the counter drugs. Call your CCO or OHA for more information.

Our plan does not have a formulary (list of covered or not covered drugs). Drugs your PCD uses in the office are determined covered based on being appropriate. If we determine a drug will not be covered, your PCD is not allowed to bill you.

If your dentist writes you a prescription, take it to the pharmacy. Show your OHP or CCO Medical ID card. We do not pay for prescriptions filled by a pharmacy. As a DCO we do not contract with pharmacies. This includes mail order pharmacies. When your dentist writes a prescription to be filled at a pharmacy either OHA or your CCO pays. Your CCO may have certain contracted pharmacies. Call your CCO for more information.

Your CCO may use a formulary. Your PCD may write a prescription not on your CCO’s formulary. Or the CCO may have limitations on when it will cover the drug. Your PCD will work with your CCO when these situations come up.

OPIATE CRISIS – Many states across the US are struggling with an opiate addiction crisis. OHA and/or a CCO may have opiate coverage criteria. This includes when an opiate prescription is written by your dentist.

FRAUD, WASTE, AND ABUSE

Fraud is intentional deception knowing the information is false. Abuse is seeking payment for services that should not be paid. The dentist did not know the coverage plan. Waste is the overuse of services that are not necessary.

Family Dental Care, Inc. takes these matters very seriously. We comply with all applicable laws. This includes the State and Federal False Claims Act. Examples of fraud, waste and abuse include:

  • Provider fraud:
    • Billing for services not rendered
    • Altering dental records
    • Kickbacks and bribery
    • Providing unnecessary services to members.
  • Member fraud:
    • Falsifying information
    • Forging a prescription
    • Letting another person use your OHP ID card
    • Identity theft.

Family Dental Care, Inc. is a community health plan. We want to make sure that healthcare dollars are spent helping our members be healthy and well. We need your help to do that. If you think fraud, waste, or abuse has happened report it as soon as you can. You can report it anonymously. Whistleblower laws protect people who report fraud, waste, and abuse. You will not lose your coverage if you make a report. It is illegal to harass, threaten, or discriminate against someone who reports fraud, waste, or abuse.

Report any suspected fraud, waste, and abuse. We are all hurt by fraud, waste, and abuse in the health care system. Every dollar that is spent this way cannot be spent where it is needed most.

If you suspect your benefits aren’t being used correctly contact us. Or if you want to report a case of fraud, waste, or abuse, contact us. There are several ways to do so:

  • You can call our toll-free hotline, call (503) 644-2663, option 4. You can call this number any time of day or night. It will take you to voicemail which is checked daily. Leave a message with your name, phone number.
  • You can leave a message anonymously.
  • You can write a letter to our Compliance Officer.
  • You can go to the ‘Contact Us’ section on our website at https://www.familydentalcareinc.com.

We will send each report of suspected fraud, waste, and abuse committed by a provider or a member to the appropriate state agency listed below.

In addition to us you can report fraud, waste, and abuse to:

  1. Medicaid Fraud Control Unit

Oregon Department of Justice

100 SW Market Street

Portland, OR 97201

Phone: (971) 673-1880

Fax: (971) 673-1890

  • OHA Office of Program Integrity

3406 Cherry Ave. NE

Salem, OR 97303-4924

Fax: (503) 378-2577

Hotline: 1-888-FRAUD01 (888) 372-8301

https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx

  • Contact DHS if you think someone is using your personal information for OHP benefits. Member Fraud can be reported to:

DHS Fraud Investigation

P.O. Box 14150

Salem, OR 97309

Hotline: 1-888-FRAUD01 (888) 372-8301

Fax: (503) 373-1525 Attn: Hotline

https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx

The law protects people who report fraud and abuse under Whistleblower laws. If you report fraud or abuse, you cannot:

  • Lose your job
  • Lose your coverage
  • Be threatened, harassed, or discriminated against

VERIFYING SERVICES

At times Family Dental Care, Inc. sends members a verification of services letter. It lets you know what services we have paid for you. This is not a bill. It is our request. Look these services over to see if they are correct. If you have doubts or believe there may be errors, call Customer Service. If you believe there may be fraud, waste or abuse involved, we want to know.

GRIEVANCE SYSTEM AND APPEAL RIGHTS

HOW TO MAKE A COMPLAINT

Are you unhappy with your dental care, Family Dental Care, Inc., or your dentist? You can complain at any time. Our “Appeals and Grievances Policies and Procedures” explains in detail how to file a complaint or request an appeal. If you would like a copy of it, call Customer Service.

A complaint can be made orally or in writing. You can make a complaint by:

  • Calling Customer Service at (503) 644-2663 or toll free at (888) 350-0996 (TTY) 711
  • Going to our website and sending us a secure message in the ‘Contact Us’ section at https://www.familydentalcareinc.com/contact/
  • You can also send us a fax at (503) 644-6488. Or a letter, our mailing address is:

Family Dental Care, Inc.

6700 SW 105th Ave.

Suite 210

Beaverton, OR 97008

With your written permission another person or provider can file for you. If a provider supports you in a complaint, we will not take any negative action against them. When receiving a complaint, we will try to make things better.

Family Dental Care, Inc. will work to resolve your complaint as fast your health condition requires. This is usually within five business days of receiving your complaint. Sometimes it is in your best interest that we need more than five days. If we do, within five days we will send you a letter to let you know why. You will receive a final answer within 30 calendar days of when we got your complaint.

Additional Information

We will not tell anyone about your complaint unless you ask us to. You may want to file a complaint and request that your name and other personal information not be shared. It is your decision if we let the provider know who filed the complaint. This helps protect members from back lash, but it may slow down solving your problem. If a provider is advised, it makes it easier to gather information about your complaint. The provider is not to treat you any differently.

You may also file a complaint with OHP Client Services at any time by calling (800) 273-0557. Or the Oregon Health Authority’s Ombudsman at (503) 947-2346 or toll free at (877) 642-0450.

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 be sent by mail in a letter called “Notice of Adverse Benefit Determination”. You have the right to ask us to change it through an appeal and a state fair hearing. You must ask for an appeal. This can be done orally or in writing. It must be done no more than 60 days from the date on the letter. With your written permission an authorized representative or provider can file for you.

How to Appeal a Decision

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.
  • Sending us an email.
  • Filling out an Appeal and Hearing Request form, OHP form OHP 3302 or MSC 443.

Do you want help filing an appeal? 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 can provide free legal advice and help.

With your written permission 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” letter 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. If we do, we will try our best to tell you personally why we need more time. We will also send you a letter in the mail in case we cannot get a hold of you. In any case, we will not take more than 14 more days. You can file a complaint at any time if you do not agree with the extension. Once the review is complete, we will send you a letter explaining our decision.

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.

Continuing Service(s)

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.

Provider Appeals

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. If you provider sends in the appeal for you all the same rules apply.

How To Get an Administrative Hearing

After an appeal you will receive a Notice of Appeal Resolution (NOAR). It will tell you if your appeal was upheld or overturned. If the services are still denied a hearing request can be filed. You can request a hearing in writing or over the phone. Call OHP Client Services at (800) 273-0557, (TTY) 711, and ask for form OHP 3302 or MSC 443.

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.

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.

Expedited Appeal or Hearing Request for Urgent Problems

Appeal – 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. For the quickest results, you can fax your appeal form to (503) 644-6488. Or you can send it by mail to: Family Dental Care, Inc. 6700 SW 105th Ave., Beaverton, OR 97008.

If you qualify for a fast appeal, we will make our decision as quickly as your health requires. We will take no more than 72 hours from the time we receive your appeal request. 

We will do our best to reach you and your provider by phone to let you know our decision. We will also send our decision in writing. 

If we need more information and it is in your best interest, we can extend the timeframe by up to 14 days. If we extend the timeframe, we will do our best to let you know orally. We will always send a written notice to let you know why we need more time. You have a right to file a grievance if you disagree with the extension. 

If we deny your request for a fast appeal, we will do our best to call you and your provider to let you know. We will also send a written notice within two days. 

Hearing – Also, you may request an expedited (fast) hearing from OHA by phone or fax. You can call OHP at (800) 699-9075. Fax your hearing request form (OHP 3302 or MSC 443) to: OHP Hearings Unit at (503) 945-6035. Include a statement from your provider explaining why it is urgent. If OHP agrees that it is urgent, the Hearings Unit will call you within three workdays.

Verbal Denial or No Written Denial Notice Issued to Member

Sometimes you may be denied services and do not receive a written notice of denial. Or sometimes your provider may tell you to pay for a service that isn’t covered without your having signed a payment waiver. If this happens you or your representative can ask for a written denial letter. Once you receive the denial notice you can ask us for an appeal.

At the back of this handbook, you will find a template of Family Dental Care, Inc.’s denial notice.

IMPORTANT INFORMATION: 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.