News
Pre-payment Medical Record Review
Date: 12/19/23
Thank you for your continued partnership with Ambetter. We are committed to continuously evaluating and improving overall payment integrity solutions as required by state and federal governing entities.
Optum supports us by performing prepayment claim auditing. The purpose of the review is to verify the extent and nature of the services rendered for a patient’s condition and to ensure that the claim is coded correctly for the services billed.
For claims received on or after February 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 providing the 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 for your continued participation and cooperation as we work together to render quality healthcare to our members.
| Review Access | Description | Lines of Business |
|---|---|---|
| Professional claims for select surgical procedures | Pre-payment medical record review for inappropriate billing of services not documented in the physician clinical notes. There is no medical necessity decision making involved. | Medicaid, Medicare, Ambetter |
| Facility NCCI modifier override | The algorithm identifies instances in which providers submit claims that utilize the NCCI bypass modifiers with CPT codes that are not allowed to be billed together for the same recipient, on same date of service, based on Medicare NCCI OCE edits. | Medicaid, Medicare, Ambetter |