ODS Commercial plans claims and appeals

Medical claims

You may dramatically reduce the processing time for your claim if you:

Submit claims electronically - ODS processes electronic claims first each day
Verify the patient's relationship to the 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 weekly.
Please contact us before submitting duplicate claims:
- Rebilling 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 interested in receiving claims electronically.

The advantages for your office include:

The claim reaches ODS faster, usually anywhere from just seconds to 24 hours, depending on the connection.
Your office and ODS have lower administrative costs.
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 and 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

RelayHealth (both medical and hospital)
One Warren Place 6100 S Yale #1900
Tulsa, OK 74136
918-481-3746

Emdeon (formerly WebMD) (both medical and 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.

ODS EDI transactions contacts

Email or by phone:

Lan T. Pham, 503-265-5632
Arlene Gaddi, 503-265-5619

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 services 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 used was on-call for the member's PCP.
Member has other primary coverage, and EOB was not received with claim.
Procedure or service is a noncovered service. Please contact ODS Customer Service to verify whether the procedure is a covered service or if you have any questions.