• Update on the Children's Program
• Program description
• Services covered
• Patient responsibility
• ID numbers
• Submitting claims
• Enrollment
• Dentist selection process
• Dentist participation process
• Appendix

Program description

ODS and the Oregon Educators Benefit Board (OEBB) have partnered together to create a much needed program called the Children’s Program. The program will provide basic dental services for children between the ages of 5 and 18 years old who reside in Oregon and are not covered under any dental plan.

Funding for the Children’s Program is provided by Oregon dentists. In addition, ODS Premier dentists that sign up for the program will provide services for reimbursement at 80 percent of their filed fees. There is no patient responsibility for covered services up to the plan maximum.

ODS will provide updates regarding the Children’s Program a minimum of once a year so the dental community can see where the dollars have been spent and the number of children served through the program. ODS is donating all administrative services to the program, thereby allowing 100 percent of the funds to go directly to the dentists that provide services to the children.

Services covered

Covered services include preventive, diagnostic, relief of pain and basic restorative services. Refer to the Children’s Program Covered Code List found in the appendix for a complete listing of covered codes.

All services must be provided prior to the plan end date. The child is covered for a year beginning on the date indicated in the Parent Letter. It is recommended that eligibility is verified prior to treatment by viewing Benefit Tracker or the Parent Letter. Both will indicate the coverage begin and end date.

Services will be covered up to a $500 maximum with no frequency limitations applied. Claims that exceed the $500 maximum will display explanation code, "L30-Dental Lifetime maximum has been met" on the Payment Disbursement Register.

The $500 maximum amount was selected to meet the program goal of providing free basic care to as many children as possible. However, we realize there may be extraordinary circumstances which may require treatment in excess of $500 to resolve the child’s pain. In this situation, you may request a review to determine if a higher maximum can be issued. To initiate this review, please contact the ODS Dental Customer Service department with the member name, member ID, procedure codes, fees and the reason the dentist feels the patient needs more extensive treatment.

Patient responsibility

There is no patient responsibility for covered services up to the $500 plan maximum.

In the rare situation where the patient’s parent or guardian requests non-covered services or services beyond the $500 coverage maximum, a financial waiver must be signed by the parent or legal guardian in advance to accept financial responsibility. In the absence of a financial waiver this treatment will become a provider write off. Please refer to the financial waiver found in the appendix of this guide.

Should the need arise for antibiotics to be prescribed to a child; it will be the responsibility of the parent or guardian to obtain and pay for the prescription.

ID numbers

ID cards will not be issued for this program. Each child will receive their own plan identification number. The number will be indicated on the Parent Letter that will be mailed to the child’s parent or guardian.

If a child is accepted for re-enrollment into this plan in a subsequent year, a new identification number will be provided

It is very important your claims to ODS are billed with the ID number provided.

The children enrolled in the Children’s Program will show the group name of the Children’s Program on the Payment Disbursement Registers and Benefit Tracker.

Submitting claims

Submitting a claim for members of the Children’s Program is just the same as submitting claims for all of your other ODS patients.

Be sure that you use the appropriate identification number assigned for the child. Remember that after a child re-enrolls onto the plan, they will be assigned a new identification number.

Predeterminations are not necessary for this plan. As long as eligibility is active and maximum has not been met, all treatment performed from the covered codes list should be a benefit.

Enrollment

The enrollment process for the Children's Program includes identifying the children eligible for the program, issuing acceptance letters and assigning children to dentists that are participating with the program.

The enrollment process will be a collaborative effort with the school districts and county health departments. Referrals from emergency rooms and pediatricians will also be considered. ODS staff will screen the applications to confirm they meet the program's criteria. This includes confirming if the child is insured with any commercial dental coverage and reviewing Oregon Health Plan records for coverage. Birthdates and addresses are reviewed to ensure the children are between the ages of 5 and 15 years of age and reside in Oregon.

Children may be eligible to re-enroll in this program if all eligibility requirements are met. The re-enrollment process is similar to the initial enrollment process where birthdates and uninsured status is identified.

If you identify a child that might be eligible for the Children’s Program, refer their parent or guardian to their school nurse or school representative to initiate the enrollment process.

Dentist selection process

It is our goal to assign members to a provider within their area. To ensure a convenient travel distance for our members and an even distribution to the provider community, each child will have a recommended dentist listed on their Parent Letter. This recommendation will be based on the address of the child. When there are multiple dentists serving an area, the members will be assigned evenly to all dentists participating in the program.

If a patient is already established with your office, and you are signed up to treat children with the Children’s Program, you are welcome to treat them even if you are not listed on the acceptance letter.

When specialist care is needed, feel free to recommend any specialist participating in the Children’s Program to your patient. These will be listed in our online Find Care directory. Participating specialists will have the Children’s Program listed under their network affiliation.

If you are not able to locate a specialist in your area or should special circumstances arise and you are unable to treat a child, please contact customer service who will assist you.

Dentist participation process

If you are interested in becoming a participating provider with the Children's Program, please contact Dental Professional Relations at 503-265-5720 or toll-free at 888-374-8905. Our representatives will be happy to mail or fax a letter of agreement and a list of all covered codes. Please note that if treatment has been provided to a member of the Children's Program and the dentist is not participating no reimbursement will be issued.

Appendix

• Covered codes list
• Financial waiver form | En Español