As a member of ODS Community Dental, you have the right to:

▪ Be treated with dignity and respect, and with consideration for your privacy;

▪ Have providers that treat you the same as they would treat other people looking

for health care benefits;

▪ Pick or change your dentist;

▪ Refer yourself directly to mental health, chemical dependency, or family planning

services without a referral from a provider.

▪ Have a friend, family member or advocate with you during appointments or other

times needed within clinical guidelines;

▪ Be actively involved in making your treatment plan;

▪ Be given information about your condition and covered and non-covered services

in a language and format you understand. This is so you can make an informed

decision about proposed treatments.

▪ Consent to treatment or refuse services and be told what will happen because of

that decision, except for court ordered services;

▪ Get written documents about your rights, benefits, how to access services, and

what to do in an emergency;

▪ Have written materials explained in a way that you understand. This includes

education on how coordinated care works and services in the coordinated health

care system;

▪ Get help getting the cultural and linguistic care you need in places as close as

possible to where you live or seek services; and pick providers that are in non- traditional settings, if available in the network, that are accessible to families, diverse communities, and underserved populations;

▪ Get oversight, care coordination, transition and planning management from ODS to ensure culturally and linguistically appropriate community-based care is provided in the best way for you.

▪ Get the services needed to diagnose your conditions;

▪ Get integrated, person-centered care and services that provide choice,

independence, and dignity; and meet generally accepted standards of practice and

are medically appropriate.

▪ Have a consistent and stable relationship with a team that manages your care;

▪ Get help navigating the health care delivery system and accessing community and

social support services, and statewide resources. This includes but is not limited to the use of certified or qualified health care interpreters, certified traditional health care workers including community health workers, peer wellness specialists, peer support specialists, doulas, and personal health navigators who are part of your care team to provide cultural and linguistic help you need to access appropriate services and participate in processes affecting your care and services.

▪ Get covered preventive services;

▪ Access urgent and emergency services 24 hours a day, seven days a week without

prior authorization;

▪ Get a referral to specialty providers for appropriate covered services;

▪ Have a clinical record that lists conditions, services received, and referrals made;

▪ Have access to your own clinical record, unless restricted by statute;

▪ Send a copy of your clinical record to another provider;

▪ Have your clinical record corrected or changed to be more accurate;

▪ Write a statement of wishes for treatment. This includes the right to accept or refuse medical, surgical, dental, or behavioral health treatment, and the right to execute directives and powers of attorney for health care established under ORS 127;

▪ Get written notices before a denial of, or change in, a benefit or service level is made, unless a notice is not required by federal or state regulations;

▪ Be able to make a complaint or appeal with ODS and receive a response;

▪ Ask for an administrative hearing;

▪ Get free qualified or certified health care interpreter services, including sign

language interpretation;

▪ Get told in a timely manner if your appointment will be cancelled;

▪ Be free from any form of restraint or seclusion used as a means of coercion,

discipline, convenience, or retaliation, as specified in other federal regulations on

the use of restraints and seclusion

▪ Be treated fairly and file a complaint of discrimination if you feel you have been

treated unfairly because of your age, color, disability, gender identity, marital

status, race, religion, sex, or sexual orientation.

▪ Share information with ODS electronically if you wish to.

As an ODS Community Dental member, it is your responsibility to:

▪ Help choose a dentist if needed;

▪ Treat all ODS Community dental staff, providers, and clinic staff with respect;

▪ Be on time for your appointments;

▪ Call ahead of time to cancel an appointment and call ahead if you expect to miss

or will be late to your appointment;

▪ Seek periodic health exams and preventive care from your primary care dentist

(PCD);

▪ Use your PCD or clinic for diagnostic and other care;

▪ Get a referral to a specialist from your PCD before seeking care from a specialist,

unless self-referral is allowed;

▪ Use urgent and emergency services appropriately and notify ODS within 72 hours

of using emergency services in the manner provided by ODS’ referral policy;

▪ Give accurate information for your clinical record so providers can give you the

best care;

▪ Help your provider get clinical records from other providers, which may include

signing an authorization for release of information;

▪ Ask questions about conditions, treatments and other issues related to your care

that you do not understand;

▪ Use information provided by ODS providers and care teams to make informed

decisions about treatment before it is given;

▪ Help in the creation of a treatment plan with your provider;

▪ Follow prescribed, agreed-upon treatment plans and actively engage in your

healthcare;

▪ Tell providers that your healthcare is covered under the Oregon Health Plan

before you get services; and if your provider asks for it, show them your Oregon

Health ID card;

▪ Call OHP Customer Service to tell them if:

o You change your address or phone number

o You become pregnant and when the baby is born

o Any family members move in or out of your household

o You have any other insurance available

▪ Pay for non-covered services

▪ Pay any monthly OHP premium on time if required

▪ Help your ODS get any third-party resources available and reimburse ODS the

amount of benefits it paid for an injury from any recovery received from that

injury.

▪ Bring issues, complaints, or grievances to the attention of ODS.

You can use your rights at any time. Using your member rights will not change the way ODS, staff, providers, and others treat you. We will not discriminate against you (treat you differently) when you use your rights. We are all here to help you get the best dental care. Our team knows about policies for Enrollment, Disenrollment, Fraud, Waste and Abuse, Grievances and Appeals, Advance Directives, and Certified or Qualified Health Care Interpreter Services. We can tell you which providers have bilingual staff. If you have any questions about these policies, please call to ask. Our ODS customer service number is 800-342-052.

Appeals

An appeal is a request to review an ODS Community Dental decision to deny, limit, reduce or terminate a requested covered service or to deny a claim payment. It can be made by a member, the member’s representative, or a provider as long as the person appealing has the member’s permission. Member appeals must be within 60 days of the decision todeny or limit services.

They also have the right to file a request for an administrative hearing with the Oregon Health Authority. The member has the right to request that the benefits continue while the case is being decided, however if the decision to terminate or limit benefits is upheld the member will be required to pay for services performed during the appeal.

An appeal may be requested as follows:

Write

Member Appeal Unit ODS

Community Dental P.O. Box 40384 Portland, OR 97240

Resolving Complaints and Appeals

Fax

503-412-4003

Telephone

ODS Community Dental OHP: 503-243-2987 or 800-342-0526 (TTY 711)

The ODS Community Dental appeals staff makes decisions about member complaints and appeals, seeking input from appropriate parties, such as the provider, dental consultant, or care coordination staff. Most complaints are resolved within five days, and most appeals are resolved within 16 days, but for more complicated complaints and appeals it may take up to 30 days to resolve.

If a member is experiencing an emergency and cannot wait for a review, they may call or write to ODS and ask for an expedited appeal. If the appeal is an emergency, we will respond to the request within 72 hours.

If ODS fails to adhere to the notice and timing requirements for extension of the appeal resolution timeframe, the member may initiate a contested case hearing.

Contested care hearing process

OHA has an appeal process for members who are dissatisfied with our response to an appeal of a denial, limitation, reduction or termination of a requested covered service or denial of claims payment. This process is outlined in the ODS Notice of Adverse Benefit Determination letter.

If a provider filed an appeal on behalf of a member, the provider may subsequently request a contested case hearing on behalf of the member with the member’s written consent, in accordance with the procedures in OAR 410-141-3900.

Members may obtain more information about this process by contacting their OHP caseworker or by contacting the ODS Community Dental customer service department at 800-342-0526.

Complaints

A complaint is an expression of dissatisfaction to ODS Community Dental or a provider about any matter that does not involve a denial, limitation, reduction, or termination of a requested covered service. Examples of complaints include, but are not limited to access to providers, waiting times, demeanor of dental care personnel, quality of care and adequacy of facilities.

We encourage you to try to resolve member complaints on your own. If you cannot resolve a complaint, please inform the member that ODS Community Dental does have a formal complaint procedure. Members can contact our customer service department to make a complaint. If a member isn’t satisfied with the way we handle a complaint the member can file a complaint with the Oregon Health Authority’s Ombudsman’s Office. There is no time limit for filing a complaint.

A member may also file a complaint directly with the state of Oregon:

Oregon Health Authority
Ombudsperson 500 NE Summer St. NE, E17 Salem, OR 97310-1097
Phone: 503-947-2346 or 877-642-0450 (TTY: 711)

Members have the right to have a representative (including their provider) file a complaint on their behalf. The member’s written consent is required in order to file a grievance or appeal on the member’s behalf.

A member may file a complaint using an OHP Complaint Form 3001 and an appeal using a Request for Administrative Hearing (MSC 443) or Appeal and Hearing Request for Medical Service Denials (OHP 3302). These forms can be found online. Complaint forms are also available on the ODS website.

Suspected Fraud, Waste and Abuse

OHP is funded by the state and federal governments. We take cases of Fraud, Waste and Abuse seriously.

Question: Who can report Fraud, Waste and Abuse? Answer: Anyone, including:

• Patients
• Providers
• Staff

How to report Fraud, Waste and Abuse:

• Call the FDCi Compliance Department toll free at 1-888-350-0996, or local at 503-644-2663 option 4; or
• Send a confidential email to [email protected]

Family Dental Care, Inc. (FDCi) follows state and federal civil rights laws. FDCi does not allow members (or potential members) to be treated unfairly due to: age, race, color, religion, disability, sex, gender identity, sexual orientation, marital status, national origin or health status.

If you think FDCi or one of our providers has treated you unfairly, you can file a complaint. If you need help filing a complaint, just call Customer Service at (503) 644‐2663 or Toll Free at 1‐ 888‐350‐0996 (TTY 711).

Family Dental Care, Inc. Attn: Compliance Officer & Non‐Discrimination Coordinator 6700 SW 105th Ave. Suite 210, Beaverton, OR 97008. Fax (503) 644‐6488. Call (503) 644‐2663. Toll Free at 1‐888‐350‐0996 (TTY 711). Email: [email protected]

Website: https://www.familydentalcareinc.com/

You can also file a complaint directly with the government. There are several ways to do so.

You can file a complaint with:

US Health and Human Services Office of Civil Rights 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201. Customer Response Center: (800) 368‐1019. TDD: 1‐800‐ 537‐7697. Email: [email protected]

Website: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

Oregon Health Authority Office of Equity and Inclusion Attn: Diversity, Inclusion & Civil Rights Manager 421 SW Oak Street, Suite 750, Portland, OR, 97204. Fax: 971‐673‐1330. Call: 844‐882‐ 7889, 711 TTY. Email: [email protected]

Website: https://www.oregon.gov/OHA/OEI/

Oregon Bureau of Labor and Industries (BOLI) Civil Rights Division 800 NE Oregon Street, Suite

1045, Portland, OR 97232. Phone: 971‐673‐0764 or 711 (TTY). Email: [email protected]

If your first language is not English, we provide FREE interpreter services, including sign language. We can also provide free materials in other formats as well, such as braille or LARGE PRINT. Please call Customer Service for help at (503) 644‐2663 or Toll Free at 1‐888‐350‐0996 (TTY 711).

Español (Spanish)

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al Call (503-644-2663) TTY (711).

Family Dental Care, Inc. (FDCi) cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

Russian

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните Call (503-644-2663) TTY (711).

Family Dental Care, Inc. (FDCi) соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной

принадлежности, возраста, инвалидности или пола.

Vietnamese

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số Call (503-644-2663) TTY (711).

Family Dental Care, Inc. (FDCi) tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa rên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

NOTICE OF PRIVACY PRACTICES

PROTECTED HEALTH INFORMATION (PHI)

What is PHI? Protected Health Information, or PHI, is any information that is specific to you and your health, such as:

• Your Medical History
• Your Medications
• Your Test Results
• Your Social Security Number
• Your Address or Phone Number
• Your Date of Birth

Here at Family Dental Care, Inc. we have systems to keep your PHI safe. Our employees get training every year on what needs to be protected, and how.

SHARING YOUR PHI

There are times when we can use and share your PHI. Some examples are:

• Managing your treatment needs
• To help your providers
• Research for our members’ benefit
• Responding to lawsuits
• Responding to government requests
• To help with public safety issues
• To obey the law

YOUR RIGHTS WITH PHI

You have rights to your PHI. The government says we must give you the chance to:

• Get a copy of this notice
• Get a copy of your PHI
• Get a list of people who have seen your PHI
• Correct your PHI if it’s wrong
• Ask us to limit who can see your PHI
• File a complaint if you think your rights have been violated
• Choose some to act for you

If you have any questions about this notice, please call Customer Service at the number above.

Read on for more information.

SHARING YOU PHI

We may use or share PHI to do business activities. These activities include things like:

For Treatment:

-Referrals and Prior-Authorizations

-Case Management or Care Coordination.

-Programs for early detection of disease.

-With law enforcement when required by law.

Health Care Operations:

-To give you more information about new treatments or benefit options.

-To help perform business with other companies, like paying your provider.

-To help public health authorities to prevent public health and safety issues.

-With research companies when approved by the appropriate governing bodies.

We will protect your PHI and make sure that all sharing of this information follows the rules above. If we use or share your information for any other reason not allowable by law, we will get your written permission.

YOU HAVE THE RIGHT TO

Get a copy of your PHI.	You must ask for this in writing. Send a letter to the address above. You will get a response within 30 days.
Correct your PHI if it is wrong.	You must ask for this in writing. We cannot change some of your information. If we cannot make the changes you asked for, we will let you know.
Get a list of people who have seen your PHI.	You must ask for this in writing. It may not include some who have seen your PHI for purposes like providers or law enforcement.
Restrict or limit us from using your PHI.	You must ask for this in writing. If there are certain people or companies, you do not want us to share your PHI with please tell us.
Share your PHI with someone.	You must ask for this in writing. If you would like someone you know to help you with your health management please tell us. We just need to know who it is, and for how long you want them to have access. Remember that once we get permission to share information, we cannot be certain that the person who gets the information from us will not share it with someone else.
Choose your method of communication.	If you would like us to send you information in a certain way, please tell us. This could be anything from using the right phone number or email, to asking us not to send any letters through the US mail. Only if required by law, we may not be able to agree with your request.
Get a copy of this notice.	At any time, you can ask us for a copy of this notice. This can be done by phone, email or US mail.

FILING A COMPLAINT

If you think your privacy has been shared when it should not have been, you may send a written complaint to our Appeals & Grievances Department. We will not react against you for your complaint.

Please send your complaint to:
    Family Dental Care, Inc.
    Attn: Appeals and Grievances Department
    6700 SW 105^th Ave., Suite 210
    Beaverton, OR 97008

You may also send your complaints to the US Department of Health and Human Services:
    U.S. Department of Health and Human Services
    200 Independence Ave. SW
    Room 509F, HHH Building
    Washington DC 20201

CHANGES TO THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. Updated notices will be available in our office and on our web site: familydentalcareinc.com.

For more information on this notice of privacy practices:

Contact the Family Dental Care, Inc. (FDCi) Compliance Officer at 503-644-2663 or toll-free at 888-350-0996, TTY 711, if you have any questions about this notice or if you want more information on privacy.

Privacy rules are overseen by the Compliance Officer, who also acts as the Privacy Officer.

This notice is effective January 2, 2020.

FDCi takes cancellations, missed appointments and no shows seriously. These are missed opportunities for dental care, and actions may be taken when a member misses 2 or more appointments. Remember to notify your dentist more than 24 hours before your appointment if you will not be able to make it. This allows dentists the time to cancel your appointment reasonably and perhaps offer the time to someone else. Sometimes things come up and we understand. The important thing is to communicate with your dental office if you can’t make it in.

Sometimes our dentists have something come up like an emergency appointment. Our clinics will also do their best in notifying members as soon as possible if there is going to be a wait for them to be seen. If the wait is longer than 45 minutes, the clinic staff will offer the member the opportunity to reschedule.

**If a Member has two or more late canceled or missed appointments this may lead to more serious actions being taken by the provider such as dismissing the patient. When a Member has missed two appointments or been dismissed for this reason FDCi will advise the Member through a letter of the seriousness of missing or late-cancelling multiple appointments and indicate that further late-cancelled or missed appointment may result in FDCi contacting the state to determine actions that may be taken.  A member who has been dismissed will be assisted by FDCi in finding a new Primary Care Dentist (PCD).