News
Optum Payment Edits
Fecha: 25/08/25
Thank you for your continued partnership with Ambetter of Alabama. 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 *10/6/2025*, providers may 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 |
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. |
Custom Fitted or Custom Fabricated Prosthetics or Orthotics | Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider. |
ER Surgical Services without Modifier 54 | Requesting medical records to determine if documentation supports services billed for ER surgical services where the follow up was not performed in the ER setting, and the correct modifier (54) was not included with the claim. |
Universal Commercial Model (UCM) | Pre-payment medical record review for claims flagged by a predictive scoring model looking for likelihood of waste and error by determining the risk of a billing error on the claim. |
Associated EX Code for EOP | Description |
EXbo | DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
Editing Area | Description |
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. |
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. |
Critical Care Coding | Medical record review to determine if critical care CPT codes are properly supported based on diagnosis codes and documentation. |
Tongue-Tie & Frenulum Procedures | Medical record review to determine if the proper coding of tongue-tie and frenulum procedures are utilized based on correct coding guidelines. |
Adjacent Tissue Transfer | When billing for adjacent tissue transfer services, providers must take great care to follow the coding guidelines, since this area presents very complex billing rules that need to be followed. Medical record review will be performed to determine if an adjacent tissue transfer was performed and if the reported defect size is supported by documentation. |
Editing Area | Description |
Trauma Activation with No Ambulance Service | 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. |
High Dollar Hardware | This analytic identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws). |
Unsupported Lab Tests on High Dollar Claims | 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. |
Cross-coder Outpatient Facility Surgical Claims | 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. |
Digital Spike Analysis | 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. |
Upcoding of Incision and Drainage Codes | 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 |
Misbilling of Third Order Selective Catheter Placement | 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. |
Cross-coder Professional vs. Outpatient Facility Surgery Claims | 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 Code for EOP | Description |
Xcelys: CPIMR | Medical Records and/or Other Service Documentation Required |
AMISYS: EXbo | MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
Editing Area | Description |
Critical Care Coding Requirements Unlikely to be Met | This review seeks to ensure appropriate critical care billing for illnesses or injuries. |
Upcoding of Percutaneous Nephrostolithotomy (PCNL) Procedures | This review of professional and outpatient claims seeks to ensure that documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure. |
Associated Code for EOP | Description |
CPIMR | Medical Records and/or Other Service Documentation Required |
Editing Area | Description |
Color Flow Doppler Echocardiography Code Review | This review seeks to ensure that an echocardiography is billed at the appropriate level based on the documentation in the medical record. |
Cross-coder Outpatient Facility CTA Claims | The review ensures the facility claim is appropriately coded based on documentation and what is submitted on the professional claim. |
Associated EX Code for EOP | Description |
EXbo | DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
Editing Area | Description |
NCCI Modifier Override – Procedure Overlap (Professional) | This review seeks to prevent overpayment of inappropriately unbundled procedures per the NCCI coding guidelines. |
NCCI Modifier Override – Misuse of Column Two Code with Column One Code (Professional) | The review ensures that procedures are reported with the most comprehensive CPT that describes the services performed. |
Associated EX Code for EOP | Description |
EXbo | DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
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.