Comprehensive Payment Integrity: Effective September 1, 2026

Date: 07/07/26

Sunflower Health Plan is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse. This is a notification that we will begin performing additional prepayment claim reviews on September 1, 2026, using Optum’s Comprehensive Payment Integrity (CPI) tool. As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.

Sunflower Health Plan utilizes widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers. These prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.

The provider will receive detailed instructions about how to submit the requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.

If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call Provider Services at 1-844-518-9505 (TTY 711).

Ambetter from Sunflower Health Plan is underwritten by Celtic Insurance Company, which is a Qualified Health Plan issuer in the Kansas Health Insurance Marketplace. ©2026 Celtic Insurance Company. All rights reserved.