News
Payment Integrity Solutions
Date: 09/12/23
Thank you for your continued partnership with Ambetter of Tennessee. 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 auditing. 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 *11/28/2023*,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.
| Editing Area | Description | Lines of Business |
|---|---|---|
| High Dollar IV Hydration | Requesting medical records to determine if documentation supports services billed and that those services were in accordance with policies and regulations related to IV hydration therapy. | Medicaid, Medicare, Marketplace |
| Custom Fitted or Custom Fabricated Prosthetics or Orthotics | Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider | Medicaid, Medicare, Marketplace |
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.