Medical Providers
• Benefit Tracker
• Pharmacy
• Referrals
• Samples and Forms
• Billing Tips
• Policies
• Disease Management

Clinical Editing Policy

ODS employs clinical edits in the processing of medical claims. Our clinical edit set focuses on correct coding methodologies and accurate, appropriate adjudication of claims.

The edits have been clinically determined and validated on a code-by-code basis. The ODS clinical edit policies are based on coding conventions defined by a variety of established sources, including –

• The American Medical Association’s CPT manual
• The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (CCI) and Associated Policies
• Coding guidelines developed by national professional specialty societies
• Specialty clinical practice guidelines
• Clinical research and practice pattern analysis
• Clinical experience of physician reviewers
• Numerous medical journals
• Medical texts
• Medical newsletters
• Coding industry newsletters
• Public health data studies
• Proprietary health data analysis
• Other general coding and claim payment references

The clinical edits are developed, maintained, and regularly updated by experienced, professional staff, including the ODS Medical Director, a large panel of board-certified physicians with specialty-matched expertise, Certified Professional Coders, and registered nurses with expertise in both medical management and clinical care.

Upon request, ODS will provide either the abbreviated or the verbatim citation of the source that defines the policy standard for a specific clinical edit.

To request a system modification to a specific clinical edit, submit a written comment including the following minimum information: the HCPCS/CPT codes and descriptors in question, the proposed modification, the justification for the proposed change, and copies of the documentation cited in the justification (e.g., National Specialty Society/Association coding guidelines, AMA's coding instructions in CPT itself or AMA's coding advice as referenced in the CPT Assistant, clinical medical literature, studies, standards of medical practice, national medical policy). Please send this written documentation to:

Mail:

ODS Medical Claims
Attention: Clinical Policy & Reimbursement Analyst
P.O. Box 40384
Portland, OR 97240

Fax:

503-243-4498
Attention: Clinical Policy & Reimbursement Analyst

E-mail:

• Home
• Members
• Employers
• Dental Providers
• Medical Providers
• Agents
• Contact Us
• Jobs
• Privacy and HIPAA

Medical insurance products provided by ODS Health Plan, Inc. Dental insurance products provided by Oregon Dental Service, doing business as Delta Dental of Alaska.