NCQA is governed by a Board of Directors that includes employers, consumer and labor representatives, health plans, quality experts, policy makers and representatives from organized medicine.
General FAQs
- What is considered a medical emergency?
- Do members need a referral for routine services such as; vision, GYN/PAP, etc.?
- What if a member is not sure if they have medical eligibility?
- How do I appeal a denied and/or reduced claim?
- Can each family member select a different PCP?
- How does a patient change from one PCP to another?
- Does an existing patient who is new to ODS need new referrals?
- How do I get information in the physician directories updated?
What is considered a medical emergency?
Emergency medical condition means a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person, or a fetus in the case of a pregnant woman, in serious jeopardy.*
Do members need a referral for routine services such as vision, GYN/PAP, etc.?
No, they can self refer to a participating optometrist for vision services or an OB/GYN for routine annual women's exam and maternity care.
What if a member is not sure if they have medical eligibility?
To verify eligibility, the provider may inquire using
Benefit Tracker. If the provider has not registered, then the member or provider should contact customer service.How do I appeal a denied and/or reduced claim?
First contact customer service for that group. If they cannot adjust the claim to pay based on any new information you give them, then you can mail an appeal letter to the ODS Complaint Management Department. The letter should state clearly and concisely why you feel it should have been paid or paid at a higher level. Chart notes or other medical documentation can be included with the appeal letter.
Can each family member select a different PCP?
Yes, if the medical plan utilizes a PCP each family member covered can select a different PCP.
How does a patient change from one PCP to another?
Patients have the option of changing PCPs within their plan's network up to two times per calendar year. The change will be effective the first of the month following the date of the request. When they have selected a PCP who is accepting patients, they should contact customer service or fill out the
online form. A new ID card will be sent to the patient within 5-10 working days.Does an existing patient who is new to ODS need new referrals?
With a new insurance carrier, historical information regarding records of referrals and authorizations do not follow. Patients should notify their PCP that their insurance coverage is now with ODS and ask him or her to call ODS with your referral information.
How do I get information in the physician directories updated?
Send a message to professional relations.
*This is our standard contract wording, the plan may be different so please reference the member handbook for what applies to the plan.