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ProCare Oregon | Transparency in Coverage


The following information is made available pursuant to Section 1311(e)(3) of the Affordable Care Act, which requires issuers of Qualified Dental Plans to make available and submit transparency in coverage data.  This information pertains to the ProCare Oregon plans underwritten by Willamette Dental Insurance, Inc.

A. Out-of-Network Liability and Balance Billing: ProCare Oregon is an exclusive provider plan that requires enrollees to use a Willamette Dental Group, P.C. provider to receive benefits.  Willamette Dental Group, P.C. is the exclusive participating provider.  

  • Out-of-Network Referrals: Participating providers may refer an enrollee to a non-participating provider for covered services.  Covered services provided by a non-participating provider are covered only if:
    • The participating provider refers the enrollee;
    • The covered services are specifically authorized by the participating provider’s referral;
    • The plan lists the covered services as covered; and 
    • The covered services are not otherwise limited or excluded.
  • Out-of-Network Emergency Treatment: Enrollees may seek treatment for a dental emergency from a non-participating provider if the enrollee is 50-miles or more from the nearest Willamette Dental Group, P.C. office.  The enrollee will be reimbursed up to the out of area emergency treatment benefit specified in the plan toward covered services provided for treatment of the dental emergency, minus applicable copayments.  The enrollee is financially responsible for any charges for covered services provided for treatment of dental emergency in excess of out of area emergency treatment benefit specified in the plan and any services not covered under the plan.  The enrollee must submit a written request for reimbursement within 6 months of the date of service.  The written request should include: the enrollee’s signature; the attending non-participating provider’s signature; and the attending non-participating provider’s itemized statement. The plan may request additional information, including x-rays, to process the request.  The reimbursement benefit for out of area dental emergency treatment is contingent upon receipt of complete information.

  • Balance Billing:  Participating providers will not balance bill enrollees for covered services.  Participating providers agree to accept the amount established by the plan and the enrollee’s payment of copayments as full payment for the covered services provided.  All benefits are expressly subject to the copayment, limitations, and exclusions of the plan.

B. Enrollee Claims Submission:  There are no claims for ProCare Oregon plans.  Enrollees do not need to submit claims for services provided by participating providers.  All benefits for services provided by participating providers are processed at the point of service.  Enrollees who seek emergency dental treatment while out of the participating provider’s service area will need to submit a request for the out of area emergency treatment benefit.  Enrollees must submit a written request for the out of area emergency treatment benefit within 6 months of the date of service.  The written request should include: the enrollee’s signature; the attending non-participating provider’s signature; and the attending non-participating provider’s itemized statement and should be submitted to:

Willamette Dental Group, P.C.
Attn: Emergency Treatment Reimbursement Request
6950 NE Campus Way
Hillsboro, Oregon 97124

If you have any questions regarding the reimbursement for out of area dental emergency treatment, please contact the Member Services Department at 1-855-433-6825.

C. Premium Payment Grace Periods:  Premium for ProCare Oregon is considered delinquent if not paid by the first day of the coverage month.  If a premium subsidy is used to pay for premium for a plan sold through the Marketplace, a 3-month grace period is granted for payment of premium.  All other enrollees have a 1-month grace period for payment of premium.  The grace period begins on the first day of the calendar month following the due date.  Grace periods are granted only for enrollees who are current on the prior months’ payment of premium.  Consecutive or rolling grace periods are not allowed.  

For enrollees using a premium subsidy to pay for premium, benefits will be provided for covered services during the first month of the grace period whether or not the due premium is paid.  Benefits for covered services during the second and third months of the grace period may be pended (not paid or denied) until the premium is received.  Enrollees will be responsible for payment of full fees to the provider for services received in the second and third month of the grace period if premium is not paid.

D. Retroactive Denials: Benefits may be denied retroactively, even after the enrollee has obtained services, when: 
  • The enrollee was not eligible at the time the service was provided,
  • The service is otherwise excluded or not covered, 
  • Coverage was not in effect at the time the service was provided, or
  • Coverage is retroactively terminated for non-payment of premium.
The enrollee may be billed for full fees by the provider for any service not covered by the plan. Certain retroactive denials can be prevented; for example, retroactive denials as a result of termination of coverage for non-payment may be avoided by paying premiums on time.

E. Enrollee Recoupment of Overpayments: If you believe you have overpaid for premiums, please contact the Insurance Department at 1-855-433-6825, to request a review of your account and a refund of premium overpayment.

F. Dental Necessity and Prior Authorization: Dental necessity is a term for describing a dental service that is required to prevent, diagnose, or treat a dental condition and which is:  
  • Consistent with the symptoms or treatment of a dental condition;
  • Appropriate with regard to standards of good dental practice and generally recognized by the relevant scientific community, evidence-based medicine, and professional standards of care as effective;
  • Not solely for the convenience of the enrollee or a provider of the service; and
  • The most cost effective of the alternative levels of dental services that can be safely provided to the enrollee.
If the enrollee requests a specific service, the participating provider will use his or her judgment to determine if the service is dentally necessary.  The participating provider will recommend the most dentally necessary course of treatment. Services which are not dentally necessary are not covered.  Please also note that a service may be dentally necessary yet excluded or not covered by the plan.  If an enrollee elects to receive a service that is not dentally necessary, the enrollee will be responsible for the full cost of the service.  Willamette Dental Insurance, Inc. does not require preauthorization for dentally necessary covered services provided by a participating provider.  Enrollees must be referred by a participating provider to receive benefits for covered services provided by a non-participating provider.

G. Prescription and Over the Counter Drugs:  ProCare Oregon does not include coverage for prescription and over the counter drugs.

H. Information on Explanation of Benefits (EOBs): An EOB is a statement an issuer sends the enrollee to explain how a claim for insurance benefits was processed for payment.  

There are no claims or EOBs for covered services provided by a participating providers or under an out-of-network referrals.  EOBs are only sent for requests for the out of area emergency treatment benefit.  

The top portion of the EOB lists the member and patient name, ID number, claim number, and the date the request was reviewed.  For each service, the EOB specifies the treatment dates (date services were performed), CDT code of the service, the amount charged by the dentist, the amount covered under the plan, the amount not covered by the plan, and applicable copayments for the.  The total patient responsibility is also listed.  This is the remaining balance owed by the patient after the dental plan’s benefits are applied.  If a member received services that are not covered by the dental plan, the member must pay the amount in full.  EOBs show corresponding reason codes that explain why a charge is not covered in full.

If you have any questions regarding your EOB, contact Member Services at 1-855-433-6825.

I. Coordination of Benefits (COB): Coordination of benefits may occur when an enrollee is also covered by another plan to determine which plan pays first.  The ProCare Oregon plan does not coordinate benefits and will pay first.

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