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Provider referral and predetermination

How can I confirm my patient’s benefits?

You can use Dental Benefit Tracker. It provides comprehensive information about your patient’s Medicaid benefits. To see the next available date for preventive services, check the preventive services box. You can also see additional benefit information on the improved Group Limitations page. And, you will find a link to the list of covered and non-covered services. Please call ODS Community Dental customer service at 800-342-0526 for help verifying eligibility and benefits.

How can I confirm my patient is not assigned to another dental office?

Some ODS Community Dental members are assigned to a specific dental office for comprehensive dental care. When accessing the Group Limitations section of Benefit Tracker, it’s important to look for messaging regarding member assignment. Services performed for a capitated member by a non-capitated provider are not covered, unless there is a referral on file.

How do I request treatment consideration for a non-covered service related to my patient’s healthcare need, comorbid condition or unique situation?

You may send a letter and supporting chart notes to ODS Dental Correspondence at 601 S.W. Second Ave., Portland, OR 97204. If we are still unable to cover the service, we will issue the member a notice of action denial letter with hearing and appeal rights.

What is the benefit of sending a letter for treatment consideration instead of predetermination?

This method allows us to have open conversations with your office to ensure that members receive the best care options.

Where can I locate a current Medicaid financial waiver?

You can find the waiver at modahealth.com. Select dental provider, resources, forms and then OHP forms. Please remember: Before you provide services, you must complete the waiver, including all requested information.

Do I need to call ODS Community Dental OHP dental customer service for a referral?

Our customer service representatives can give you names of participating Medicaid specialists upon request. If you have a relationship with a specialist who your office prefers to send patients to, and they participate on our Medicaid panel, you are welcome to refer your patient directly.

Can my patients call for a referral?

No, referrals to and from a primary care dentist are part of the member’s treatment plan and need to be made by the member’s primary care dentist.

Is your panel open for additional Medicaid specialists?

Yes, our Medicaid panel is open. We strive to work with our dentists in a partnership to provide quality care and access for our members. If you have a specialty office you work closely with who would like to join our panel, please ask them to contact our dental professional relations team at 503-265-5720.

I am a capitated dentist for ODS Community Dental. How does the referral process affect me?

When you refer your patient to a specialist, please notify us by email at dentalcasemanagement@modahealth.com with the following information:

  • Patient name
  • Member ID
  • Specialist name/location
  • Procedure(s)
  • Tooth number(s)
  • Timeframe if applicable

I am a specialist for ODS Community Dental. How does the ODS Community Dental referral process affect me?

The member’s primary care dentist will refer their patient to your office directly. You must confirm the member’s eligibility on the date of their appointment. It is also important to check the Group Limitations section of Benefit Tracker to see if the member is assigned to a dental office. If the member is assigned to a dental office, contact the referring provider or ODS Community Dental customer service to confirm a referral has been submitted. Services performed for a capitated member by a non-capitated provider are not covered, unless there is a referral on file.

How do I refer my patient with special healthcare needs?

Contact ODS Community Dental case management at 844-274-9124 for assistance with special needs referrals. We offer dental case management to all members with special healthcare needs. We also engage with the members, caregivers and primary care dentists to ensure members receive treatment, and to coordinate and meet access needs.