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Optum Payment Integrity - Editing Area: Effective September 1, 2026

Date: 07/08/26

Thank you for your continued partnership with Sunflower Health Plan. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim review. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.

For claims received on or after September 1, 2026, providers my experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement. Announce or describe the Who, What, When, Where and Why. Make sure to spell out acronyms on first reference where possible.

Line of Business: Medicare, Marketplace, Commercial

Editing Area: Trauma Activation with No Ambulance Service

Editing Description:  This analytic will identify outpatient claims with revenue codes for trauma response (Rev 681 – 689) when there are no claims in history for ambulance services with HCPCS codes between A0021 and A0999 for the same member on the same date of service.

Editing Area: High Dollar Hardware

Editing Description: This analytic identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws).

Editing Area: Unsupported Lab Tests on High Dollar Claims

Editing Description: This analytic reviews 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.

Editing Area: Cross-coder Outpatient Facility Surgical Claims

Editing Description: This analytic identifies 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. Records will be reviewed to ensure coding/documentation guidelines are met.

Editing Area: Digital Spike Analysis

Editing Description: This analytic will target when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify the required additional time and extra work was done to support the billing of this code.

Editing Area: Upcoding of Incision and Drainage Codes

Editing Description: This analytic identifies claims billing incision and drainage (I&D) procedure codes that are suspected to be non-incision or lower-level incision and drainage which may have been incorrectly submitted to achieve additional reimbursement, reviewing simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081.

Editing Area: Misbilling of Third Order Selective Catheter Placement

Editing Description: This algorithm targets codes for arterial selective catheter placement of the third order for placement above the diaphragm (36217) and below the diaphragm (36247) when claim details suggest that 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. 

Editing Area: Cross-coder Professional vs. Outpatient Facility Surgery Claims

Editing Description: This analytic identifies professional claims with surgical procedure codes that do not match the outpatient facility claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met.

Associated EX Code for EOP: EXbo: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call us at the numbers below:

 

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.