CurrentmhnPolicy CC.PP.074

Payment Policy: Optum Comprehensive Payment Integrity (CPI)

Defines Optum CPI's pre-pay claim editing process for facility and professional claims affiliated with Centene, including medical record requests, review criteria, and dispute procedures for providers.

Policy Summary

Payermhn

PolicyPayment Policy: Optum Comprehensive Payment Integrity (CPI)

Policy CodePolicy CC.PP.074

Change TypeNo material change

Effective DateApr 1, 2023

Next Review DateMar 12, 2025

Key ActionProviders must submit requested medical records via secure upload, US mail, or CD/DVD per instructions in the medical records request within 30 calendar days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysprovider response timeframe to submit medical records

120 daysdenial sent if records not received

7 bdtarget record review TAT

ALLproduct types

~40+types of records possibly required

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OASIS specific requirements

Documentation & Policy Scope

Documentation and review criteria

Optum CPI will review claims and supporting medical records against a set of documentation criteria; lack of supporting documentation may result in denial or adjustment.

ALL of the following

Providers should submit requested medical records to the address in the medical record request letter within 30 calendar days.
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; specific provider contract timeframes may apply.
Failure to submit records within the timeframe may result in a technical denial; providers may submit records afterward for review but submission is not a guarantee of payment.

ALL of the following

Optum performs a holistic review of all billed services on the claim and matches them to the submitted medical documentation; the CPI review does not determine medical necessity.
Documentation must support patient demographics (name, DOB), dates of service, units (except inpatient), modifiers (as applicable), CPT/HCPCS coding, bundling/unbundling (NCCI), place of service, provider signature/attestation, and signature date (signature date must be within 30 days of date of service).

ALL of the following

For inpatient claims, documentation must support the DRG billed and the correct ICD-10-CM diagnosis code(s).
Documentation must support ICD-10-PCS procedure code(s) billed and additional DRG drivers such as patient's sex and discharge status.

ALL of the following

Submission of records does not guarantee payment; trained coding professionals will examine documentation and recommend to the Health Plan to pay, deny, or replace billed services based on whether records support how the claim was billed.
Optum may recommend denial even if prior authorization existed when records do not support the billed services; if a claim line is denied, provider will receive a detailed letter with rationale.

ALL of the following

Examples include
- Operative reports
- Laboratory and pathology reports and requisitions
- Medication administration records including NDCs
- Progress notes and face-to-face encounter documentation
- Delivery receipts for DME/home infusion
- Plans of care (POC), treatment plans, therapy logs with minutes documented

ALL of the following

Submitted or resubmitted records that are incomplete or missing pages so that billed charges cannot be verified.
Records lacking sufficient detail to support billed charges (e.g., missing E/M notes, missing treatment details, missing supporting documentation for units or time).
Absence of documentation for the specific date of service billed.

Policy scope and precedence

Policy purpose and legal/administrative notes

ALL of the following

This payment policy provides guidance to assist in making coverage and payment determinations and administering benefits but does not constitute a contract or guarantee of payment; coverage and payment determinations are subject to plan documents, state and federal requirements, and applicable plan-level administrative policies and procedures.
Health Plan retains the right to change, amend, or withdraw this payment policy; the policy may be subject to legal and regulatory requirements and the effective date determined by the Health Plan may differ from the posting date.

ALL of the following

For Medicaid members, when state Medicaid coverage provisions conflict with this payment policy, state Medicaid coverage provisions take precedence; refer to the state Medicaid manual for applicable coverage provisions.

ALL of the following

Codes & OASIS Requirements

Code sets subject to Optum CPI editingmixed

ICD-10-CM	Diagnosis codes eligible for claim editing and review
CPT	Procedure codes eligible for claim editing and review
HCPCS	Procedure/supply codes eligible for claim editing and review
DRG	DRG codes subject to inpatient review

OASIS coding requirementICD-10Covered

OASIS diagnosis codes

All six digits of the diagnosis code must exactly match between Plan of Care (POC), OASIS and the claim; corrections must be applied by end of episode. Fields cannot contain N/A. Fields M2200 and M0110 cannot be blank or contain N/A.

OASIS field completion

OASIS field completion requirementOASIS fields cannot contain 'N/A'; specifically, fields M2200 and M0110 cannot be blank or contain 'N/A'.

Diagnosis code consistencyAll six digits of the diagnosis code must exactly match between Plan of Care (POC), OASIS and the claim; corrections must be applied by the end of the episode.

Scope of OASIS requirementRequirement applies to the Outcome and Assessment Information Set (OASIS) for home health claims, completed in its entirety.

Medical Record Requests & Disputes

Documentation Required

Medical record submission

Optum will generate a medical records request (MRR) letter and will send the letter directly to providers. The MRR will include directions on how or where to submit the records. Centene sends an electronic Explanation of Payment (EOP) to providers with a message indicating the reason codes for the medical record request. CPIMR and explanation code 'bo' indicate a claim has been flagged for medical record coding review. CPISI indicates a claim has been flagged at the request of Centene's Special Investigation Unit (SIU).

MRR letters include submission directions and may be sent directly by Optum.
EOP messages include reason codes (e.g., CPIMR, CPISI) to indicate flagged claims.

Documentation Required

Instructions for providing documentation

The requested information can be provided by one of the methods listed below. Documents should be organized by placing all medical records for a recipient and date of service behind the enclosed barcoded cover sheet on which the recipient's name and the date of service are printed. Note: Secure Internet Upload does not require the cover sheet be included with the documentation submission. Document submission options include electronically via secured internet upload, US Mail, or CD/DVD. 1. SECURE INTERNET UPLOAD: Using a web browser, go to https://sftp.databankimx.com/form/RecordUploadService and follow the directions outlined in the MRR, including the authorization code. 2. HARD COPY (paper copy): Use the address listed in the MRR or (FedEx, UPS): OPTUM 458 Pike Road Huntingdon Valley, PA 19006.

Key Terms & Operational Notes

Optum CPI Claims Process

Process overviewOptum CPI applies a systematic algorithm to identify aberrant (waste and error) billing patterns at the claim-line level.

Actions that may follow flaggingOptum CPI may deny claims and may request medical records from the provider or supplier who submitted the claim to support the services billed.

Potential referralAberrant billing patterns may be referred to the Special Investigations Unit (SIU) for further internal investigation when indicated.

Explanation of Payment (EOP)

DefinitionExplanation of Payment (EOP) is an informational letter sent to providers that gives details on claims that have been paid, denied, or adjusted.

Reason codes indicating record requestsReason codes CPIMR/CPISI indicate 'medical records and/or other service documentation required.'

Policy Summary

Payermhn

PolicyPayment Policy: Optum Comprehensive Payment Integrity (CPI)

Policy CodePolicy CC.PP.074

Change TypeNo material change

Effective DateApr 1, 2023

Next Review DateMar 12, 2025

Key ActionProviders must submit requested medical records via secure upload, US mail, or CD/DVD per instructions in the medical records request within 30 calendar days.

SourceLink

On This Page

Anesthesia records, consultation notes, operative reports, X-rays and written interpretations

For Medicare members, review all applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to applying the criteria in this payment policy; refer to the CMS website for additional information.

ALL of the following

This payment policy is not medical advice and is not intended to dictate clinical practice; providers remain responsible for medical judgment and treatment of members.
The policy is the property of Centene Corporation; unauthorized use or distribution is prohibited and contractual terms govern provider, member, and representative obligations.

Organize records behind the barcoded cover sheet (unless using Secure Internet Upload).
Acceptable submission methods: Secure Internet Upload, US Mail, CD/DVD.

Documentation Required

Medical record requests for review

Optum CPI may request a wide range of medical records and supporting documentation to complete claim review. Types of records that may be requested include, but are not limited to: ADL sheets/flow sheets/logs; admission assessments; anesthesia records (including time of administration); case management notes; change of therapy assessments; chemotherapy orders; clinical trial documentation; consultation and diagnosis notes; discharge/transfer summaries; photos/drawings; emergency department reports; evaluations related to the service; face sheets and face-to-face encounter documentation; delivery receipts or proof of delivery for DME/home infusion/home health; PAI for inpatient rehabilitation; MDS for skilled nursing facilities; hospice/end-of-life documentation; implant details and invoices; laboratory/pathology requisitions and ordering physician records; lab reports and X-rays with written interpretations; medication records/MARs (including NDC, waste, mixing logs, infusion/transfusion logs); nurse and provider progress/treatment/SOAP notes; operating and operative reports; patient history and physical exam; complete physician office records; physician orders; plans of care/treatment plans and recertifications signed by a qualified provider; preanesthetic, preoperative and postoperative notes; prescriptions; progress and psychiatric evaluation notes; physician queries (if applicable); skilled nursing and therapy documentation with minutes; test orders/results/reports; OASIS for home health (completed in entirety, with matching diagnosis codes); toxicology reports; treatment notes; UB-04/HCFA 1500 forms; and wound care assessments.

Provide complete records relevant to the date(s) of service requested.
Include supporting documentation such as orders, test results, therapy logs, implant invoices, and delivery receipts when applicable.
OASIS for home health must be completed fully and diagnosis codes must match between POC, OASIS and the claim.

Note

Dispute process

Providers have dispute rights on all claim denials. Upon receipt and review of records, if at least one line on a claim is denied, the provider will receive a denial letter explaining the rationale and instructions for submitting a first level dispute. Optum performs the first level dispute for CPI reviews and will send a dispute acknowledgement and a dispute response letter with the outcome and instructions for submitting a second level dispute to Centene. Second level disputes are handled by Centene. If the provider disagrees with the second level outcome, refer to the health plan's Quick Reference Guide (QRG) or Provider Manual for additional instructions on disputing or submitting an Appeal. All communications sent by Optum are shared with Centene for record retention.

First level dispute handled by Optum (CPI program).
Second level dispute handled by Centene; further appeal instructions available in plan QRG or Provider Manual.

Reason code indicating denial requiring documentationReason code 'bo' indicates 'DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED.'

Turnaround Time (TAT)

DefinitionTurnaround Time (TAT) is the time interval from the submission of a claim to the completion of the adjudication process.

Use in policyTAT is used as the standard measure for processing and review timelines in the CPI program.

Relation to record reviewThe policy identifies target review intervals (e.g., record review target of 7 business days after receipt).

Health Plan

Definition of Health Plan'Health Plan' means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates.

Policy roleThis payment policy is guidance to assist in coverage and payment determinations and does not constitute a contract or guarantee of payment.

Precedence and applicabilityCoverage and payment determinations are subject to plan documents, state and federal requirements; Medicare NCDs/LCDs should be reviewed where applicable.