Optum Comprehensive Payment Integrity Claim Review Phase 4

Date: 05/03/24

Optum Comprehensive Payment Integrity Claim Review Select Surgical Procedures & Facility NCCI Modifier Override Effective for Claims Received on or After 6/3/2024

Optum is performing prepayment claim auditing for us to verify the extent and nature of the services rendered for the member’s condition and confirm claims are coded correctly for the services billed. The goal is to identify aberrant billing patterns that require further review to confirm there is no waste or error on the claim(s) as billed. Edits are not applied as a blanket “rule” for all claims. Only a small number of claims that meet the criteria will be chosen for review.

As a result, for a small subset of claims received on or after 6/3/2024, you may experience a slight increase in claims denied for medical record submission based on the editing areas outlined in the table below. You also will receive a letter requesting medical records from Optum that contain instructions for submitting the documentation. You will have the ability to request that Optum rereview their findings in the event of a disagreement.

Editing Area	Description	Lines of Business
Professional Claims for Select Surgical Procedures	Pre-payment medical record review to confirm services are documented in physician clinical notes. There is no medical necessity decision making involved. Targeted specialties include: Cardiology, Dermatology, ENT, General Surgery, Hand Surgery, Neurology, Neurosurgery, Orthopedic, Pain Management, Physiatry, Plastic Surgery, Podiatry Sports Medicine, Urology	Medicaid Medicare Marketplace
Facility NCCI Modifier Override	Algorithm identifies instances in which claims are submitted that utilize the NCCI bypass modifiers with CPT codes not allowed to be billed together for same member, on same date of service, based on Medicare NCCI OCE edits. Targeted Procedure Codes: CPT Codes 00000 – 98999 on Medicare’s NCCI list	Medicaid Medicare Marketplace

References Medicaid National Correct Coding Initiative Policy Manual Medicare Claims Processing Manual Chapter 12 CMS Correct Coding Policy

Remittance Advice Code	Description
EXbo	DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED

 

AzCH providers and staff: If you have questions, please contact your
AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.