Improving Payment Integrity Solutions

Date: 10/16/23

Thank you for your continued partnership with Ambetter of Illinois. We are committed to continuously evaluating and improving payment integrity solutions as required by state and federal governing entities.

We have partnered with Optum to support us in performing prepayment claim auditing. The purpose of a review is to verify the extent and nature of services rendered for a patient’s condition and that a claim is coded correctly for the billed services.

For claims received on or after January 1, 2024, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below.

Requests will come from Optum and will contain instructions for submitting documentation. If the requested documents are not returned, the claim(s) will be denied. Providers will have the ability to dispute findings directly through Optum in the event of a disagreement.

Thank you again for your cooperation and continued participation in our ongoing efforts to render quality healthcare to our members.