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.
Claims
ODS Commercial Plans
Medical Claims
Helpful hints to reduce claims processing time!
- Submit claims electronically. ODS processes electronic claims first each day.
- Verify the patient's relationship to subscriber and plan information is correct before submitting claims.
- Include all pertinent information. Date of birth, subscriber ID, valid CPT and ICD-9 codes.
- If the patient is covered by more than one ODS program, submit one
claim form indicating the name of the subscriber, subscriber ID, employer
(if applicable), and ODS group number for both plans. If covered by
another carrier, indicate the above information plus the name, address
and policy number of the other carrier.
If a patient has primary insurance through another carrier other than ODS, the EOB from that insurance company will need to accompany the claim for consideration of payment. - ODS makes payment twice per month.
- Please contact us before
submitting duplicate claims:
- Re-billing without contacting us slows our turnaround time and delays payment.
- Check Benefit Tracker to see the status of a claim. If you haven't registered for this free online service, click here for more information.
- If you receive a PDR indicating that your claim has already been processed before you receive a check, this indicates your re-bill was unnecessary. The claim was processed and is pending for the next scheduled payment date.
- DO NOT USE HIGHLIGHTER ON PAPER CLAIMS.
Electronic Claims and other Transactions
ODS is very interested in receiving claims electronically.
The advantages for your office include:
- The claim reaches ODS more quickly, usually anywhere from seconds to 24 hours, depending on connection.
- Lower administrative costs for your office and ODS
- Because electronic claims require consistent, accurate information, the incidence of returning claims to your office is reduced.
Below is a list of Medical and Hospital Electronic Claims Providers for ODS:
- McKesson (both Medical & Hospital)
700 Locus St. #500
Dubuque, IA 52001
(563) 557-3925 - Availity
12400 Coit Rd #700
Dallas TX 75251
(800)282-4548
Payor ID = 13350 - Cortex EDI
737 W Oakcrest Ave
Brea CA 92821
(714) 529-8560 - MCPS Inc
1740 S Glenstone B
Springfield MO 65804
(417) 890-6164 - Per-Sé Technologies (formerly NDC Health) (both Medical & Hospital)
One Warren Place 6100 S Yale #1900
Tulsa OK 74136
(918) 481-3746 - Emdeon (formerly WebMD) (both Medical & Hospital)
26 Century Blvd 5th fl
Nashville TN 37214
(615) 231-7901
Payor ID = 13350
Systems that submit Directly to ODS
- LINCARE Inc.
19387 US 19 N
Clearwater , FL 33764
(727)431-8231
Direct Connection to ODS
ODS also supports direct connections between offices and ODS if the doctor or health system prefers this method.
The transaction standard is the 837 Professional Claim or 837 Institutional Claim required by HIPAA Administrative Simplification.
If you have questions, please call Pat Van Dyke at (503) 243-4492 or 1-800-852-5195 extension 4492.
ODS EDI Transactions Contacts
- For 835-Electronic Remittance Advice/ Electronic Funds Transfer
Lan T. Pham, (503) 265-5632, - For 837- Electronic Claims
Arlene Gaddi, (503) 265-5619, - For 834-Enrollment, 270/271- Eligibility and Benefits, 276/277-Claim Status
Kathy Turner, (503) 243-4487,
Reasons For Denied, Paid At a Lower Benefit, or Returned Claims
- Patient is not eligible. A member's card is NOT a guarantee of eligibility.
- Coverage has terminated.
- Claim received with incomplete information. Please remember to include the following:
- Subscriber ID
- Group number
- Date of birth
- CPT Code
- ICD-9 code
- Full name and address of provider with the tax ID number
- No authorization on file for procedure.
- No PCP selected by member.
- Member was seen by specialist for routine services. These must be done by the member's PCP.
- Member was seen by PCP's on call physician and claim did not indicate this. Please indicate by stating on top of claim "ON CALL." This will alert our processors that the physician utilized was on call for member's PCP.
- Member has other primary coverage and EOB was not received with claim.
- Procedure or service is a non-covered service. Please contact customer service to verify if the procedure is a covered service or if any questions.
ODS Advantage Plans
Non-contracted Provider Appeals
Provider payment disputes subject to CMS’ independent review process include any decisions where a non-contracted provider contends that the amount paid by the organization for a covered service is less than the amount that would have been paid under Original Medicare.
Instructions for submitting your written appeal
Once an organization makes its internal decision about an initial payment dispute filed by a non-contracted provider, the provider has the right to request and independent decision from CMS’ Payment Dispute Resolution Contractor, First Coast Service Options, Inc. (FCSO). In addition, if the organization fails to make a decision in response to a non-contracted provider dispute request within 30 days from the date the dispute request was received by the organization, the provider may request a Payment Dispute Decision (PDD) without having received an initial internal dispute decision by providing evidence to FCSO of the dispute it filed with the organization. Such disputes are subject to CMS review because organizations are required to pay non-contracted providers the same amount as they would have received had they billed Original Medicare.
Filing a request for an independent payment dispute resolution
Oregon Health Plan (OHP)
The Prioritized List
The Oregon Health Services Commission maintains a list of condition and treatment pairings known as the List of Prioritized Health Services. These pairings have been ranked by priority from most important to least important and subsequently assigned a line number from 1 to 680. Services prioritized as most important are funded by the State. The funding level is set at a line designated by the State. This means any pairing that occurs above the line is considered funded. Any pairing that occurs below the line is not funded. Below the line services are typically categorized as treatments that do not have beneficial results, treatments for cosmetic reasons, and conditions that resolve on their own.
The Oregon Health Plan and ODS cover all funded services.
Getting Started
To verify whether a service is covered by ODS, and to find out where the line is currently set, check the List of Prioritized Services. You can access the list for free by visiting the DHS website under Current Prioritized List. In addition to the list, DHS has also provided a searchable index to assist you with locating which line(s) a condition or a treatment is listed.
Important to Know
Due to legislative decisions, the funding line is subject to change. For the most current information, be sure to check with either DHS or ODS.
Treatment may be covered for one condition but not covered for another. For example, arthodesis may be covered for a dislocation but not covered for an anomaly. Remember, the pairing of the condition with the treatment determines which line the service is on.
The List of Prioritized Health Services applies to both the Plus and Standard benefit packages. However, the Standard plan is further restricted by the Limited Hospital Benefit. More information on the Limited Hospital Benefit can be found at:
http://www.dhs.state.or.us/policy/healthplan/guides/hospital/main.html
Reasons For Denied or Returned Claims
A Clean Claim means a claim that has no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment in accordance with the Member's Health Benefits Plan and this Agreement.
A Clean Claim shall not include those claims which require coordination of benefits and third party liability issues until receipt of Explanation of Benefits from primary carrier or claims, which are being reviewed by the Medical Director, Medical Consultant, or Peer Review for medical necessity.
A clean claim shall accurately reflect billed Charges. “Substantiating Documentation” includes, but is not limited to:
- Legible claim form—CMS UB 92, CMS 1500 or other required forms
- Full Name of Patient/OHP Member
- OHP Member's Date of Birth
- OHP Member's Recipient ID Number
- Date(s) of Service
- Place of Service
- CPT Procedure Code
- Modifier(s) if applicable
- Line Item and Total Charges
- Quantity of Units of Service
- ICD-9 CM Diagnosis Code (to the highest specificity)
- Physician's Name and Address
- Physician's Tax ID Number
- Physician's OMAP ID Number
- Outpatient Hospital Services
- Bill type
- Admission date and time
- Discharge date and time
- OMAP billing number for Facility
- Revenue Center Code
- Date of Service for each line item
- Quantity of units of service
- Line item charges
- ICD-9 CM Diagnosis Code (to the highest specificity)
- CPT HCPC code
- Attending Provider OMAP Provider Number
- Inpatient Hospital Services & Inpatient Nursing Facilities
- Bill type
- Admission date and time
- Discharge date and time
- OMAP Hospital/Nursing Facility Billing Provider Number
- Type of Admission Code
- Patient Discharge Status Code
- Date of Service (dates of admission through discharge)
- Dates of Service through discharge except continuous stay nursing facility clients
- (Use the last day of the month or the discharge date)
- Revenue Center Code(s)
- Line item charge(s)
- Total Charge
- ICD-9 CM Diagnosis Code (to the highest specificity)
- ICD 9 CM Procedure Code when a procedure is performed
- Attending Physician OMAP Provider Number
- Written referral, if applicable
A Clean Claim shall not include those claims which require coordination of benefits and third party liability issues until receipt of Explanation of Benefits from primary carrier or claims, which are being reviewed by the Medical Director, Medical Consultant, or Peer Review for medical necessity.
Vaccines for Children Billing
The Vaccines for Children (VFC) Program is a federal program that provides free immunizations for children age 0 – 18 years.
ODS does not reimburse for the cost of vaccine serums covered by the VFC Program. Providers should bill ODS only for the administration of the vaccines covered under the VFC Program.
Providers should bill the specific immunization CPT code with modifier 26 or SL, which indicates administration only. Providers should not bill for the administration of these vaccines using CPT codes 90465-90474 or 99211 (immunization administration codes).
ODS is unable to reimburse providers who do not participate in the VFC Program for the cost of the serum. Providers not participating with the VFC Program can direct their patients to the County Health Department to receive the vaccines covered under the program. A County Health Department can bill ODS for the administration of the vaccines.
The following CPT codes are covered under the Vaccines for Children Program:
| 90633 | 90634 | 90645 |
| 90647 | 90648 | 90649 |
| 906551 | 906562 | 906571 |
| 906582 | 906604 | 90669 |
| 90680 | 90700 | 90702 |
| 90704-8 | 90710 | 90713 |
| 90714 | 90715 | 90716 |
| 907213 | 90723 | 90732 |
| 90733 | 90734 | 90743 |
| 90744 | 90748 | 90749 |
| S0195 | ||
1 All children ages 6-35 months. |
||