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Optum Payment Integrity - Professional Claims for Select Surgical Procedures: 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: Professional Claims for Select Surgical Procedures

Editing Description: 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.

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.