Optum Pre-Payment Claim Review Expansion Effective October 15, 2025
Date: 09/15/25
Optum Pre-Payment Claim Review Expansion Effective October 15, 2025
Starting with claims received on and after October 15, 2025, we are expanding our partnership with Optum to include additional pre-payment claim reviews. These reviews ensure that medical records support the billed service.
Note: Claim lines already denied due to other payment integrity or coding edits will not be reviewed again.
This update applies to all lines of business: Arizona Complete Health-Complete Care Plan (Medicaid), Ambetter from Arizona Complete Health (Marketplace), and Wellcare by Allwell/Wellcare (Medicare).
*Edit Scenarios
Editing Area | Description |
Trauma Activation with No Ambulance Service | Outpatient claims with revenue codes for trauma response (Rev 681 – 689) are identified when there are no claims in history for ambulance services with HCPCS codes A0021- A0999 for the same member on the same date of service. |
High Dollar Hardware | Outpatient claims billed with C1713 for implantable anchor or screw fixation devices to validate adherence to coding rules. |
Unsupported Lab Tests on High Dollar Claims | High dollar lab claims with at least 5 lines and a payment greater than $500 that are potentially unsupported by an order from a qualified healthcare professional. |
Cross-coder Outpatient Facility Surgical Claims | Outpatient facility claims with surgical procedure codes that do not match the professional claim codes for similar services provided to the same patient on the same date of service are identified and records reviewed to confirm coding/documentation guidelines are met. |
Upcoding of Incision and Drainage Codes | Claims billed with incision and drainage (I&D) procedure codes that are suspected to be non-incision or lower-level I&D. Includes review of simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081 |
Misbilling of Third Order Selective Catheter Placement | Codes for arterial selective catheter placement of the third order for placement above the diaphragm (36217) and below the diaphragm (36247) are reviewed when claim details suggest a first or second order arterial branch above the diaphragm or below the diaphragm was more likely the location of the procedure. Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. |
*State or Federal guidelines, when applicable, will take precedence over these edits.
Medical Record Requests
Optum will send instructions for submitting documentation. If records are not provided, the claim(s) will be denied. Providers may submit a disagreement with Optum’s findings to Optum directly as well as follow established health plan claim issue resolution procedures.
Remit Adjustment Code | Description |
Wellcare: CPIMR | Medical Records and/or Other Service Documentation Required |
Arizona Complete Health-Complete Care Plan, Ambetter from Arizona Complete Health, and Wellcare by Allwell: EXbo | MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
Questions?
Contact your Provider Engagement Account Manager. Need their contact information? Email us at: 📧 AzCHProviderEngagement@azcompletehealth.com