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• Providers should submit requested records to the address or method specified in the MRR within 30 calendar days of the MRR date.
• Specific provider contract timeframes may apply and supersede this timeframe where applicable.

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• Submitted or resubmitted records that are incomplete, missing pages, or lack sufficient detail (e.g., missing E/M notes, treatment information, unit documentation, time records) may result in inability to verify billed charges and lead to denial.
• If Optum does not receive the requested records, Optum will make a determination based on available information which may result in the claim being denied or the denial being upheld. If records are not received by 120 days after initial request, a denial letter may be issued.

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• Upon receipt, Optum will review medical records (target ~7 business days) and trained coding professionals will determine whether billed services are supported.
• The provider's submission of records is not a guarantee of payment; Optum makes a recommendation to the Health Plan to pay, deny, or replace billed services based on documentation. Providers will receive a detailed Optum letter explaining denial rationale if payment is denied.

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• Patient demographics and date(s) of service must match the claim.
• Units, modifiers, CPT/HCPCS codes, place of service, and provider signature/attestation (including signature date within 30 days of service) must be supported in the record (some items not in scope for inpatient review).

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• MRR will include directions for submission (secure internet upload, mail, or physical media) and contact information; follow the MRR instructions.

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• Providers have dispute rights for denials; Optum/Centene processes disputes per plan procedures.

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• Submission of records does not constitute medical necessity determination; Optum may deny services not supported by documentation even if prior authorization exists.

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• Provider response: 30 calendar days to submit records from MRR.
• Optum review target: within 7 business days after receipt.
• If no records received by 120 days, denial letter may be issued.

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• If payment of the claim line is denied, providers will receive a detailed letter from Optum and Centene will also send denial explanations via EOP.

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• Providers should maintain and submit complete records to avoid denials or adjustments; failure to provide adequate documentation can result in claim denials, adjustments, or referral for further investigation.

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• Trained coding professionals examine documentation and recommend pay/deny/replace to the Health Plan based on whether records support the billing.

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• Submission of records does not guarantee payment and Optum may deny billed services not supported by records. Specific contract timeframes may apply.

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• Follow contact and submission instructions included in the MRR (see MRR for secure upload URL and PIRT contact information).

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• This payment policy is a guide to payment and a component of the guidelines used to assist in coverage and payment determinations; it is not a contract or guarantee regarding payment or results. Coverage and payment determinations are subject to plan documents and applicable law.

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• If state Medicaid provisions conflict with this payment policy, state Medicaid provisions take precedence.
• For Medicare members, applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this policy.

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• This payment policy is the property of Centene Corporation; unauthorized copying, use, or distribution is prohibited.

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• Provide specified complete documentation upon request, including but not limited to physician office records, orders, plans of care and recertifications signed by a qualified provider, pre/post-operative notes, therapy documentation/logs with minutes, test results, OASIS for home health (with required fields), UB-04/HCFA 1500 forms, anesthesia and operative reports, consults, discharge summaries, lab/pathology reports, medication administration records (including NDCs), and other items listed in the MRR.

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• All six digits of the diagnosis code must exactly match between fields as documented; OASIS fields M2200 and M0110 cannot be blank or contain 'N/A'.
• Corrections to OASIS must be applied by the end of the episode.

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• Providers are expected to exercise professional medical judgment in providing care and are solely responsible for medical advice and treatment; submission of records and the policy do not substitute for clinical decision-making.

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• When requested, provide complete and signed documentation as specified in the MRR; incomplete documentation is a common reason for denial.

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• The payment policy is effective as determined by the Health Plan; Health Plan may change, amend, or withdraw the policy as needed, subject to law and regulation.

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• Providers, members and their representatives are bound to the terms and conditions through their contracts; where no contract exists, providing services or submitting claims constitutes agreement to be bound.

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• See the additional documentation section and the MRR for the specific list of document types that may be requested; the list in the policy is illustrative and not exhaustive.