CurrentMolina HealthcarePolicy N/A

Optum Pause & Pay payment accuracy solution

Defines Molina Healthcare's process for Optum-led pre-payment review of claims to ensure coding and billing accuracy; affects providers submitting claims to Molina across all states and lines of business.

Policy Summary

PayerMolina Healthcare

PolicyOptum Pause & Pay payment accuracy solution

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2020

Next Review DateN/A

Key ActionProviders must submit requested medical records via secure upload, fax, or mail when notified with Remit Remark Code M127.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All States & LinesGeographic/lines applicability

10 business daysReview turnaround

1-877-244-0403Provider Inquiry

M127Remit remark code

01/01/2020Effective date

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Pre-payment review criteria and outcomes

Claims selected for Optum pre‑payment review require submission of supporting documentation; review outcomes may result in full payment, partial payment, or denial based on the documentation and coding verification.

Provider receives an Explanation of Payment (EOP) notifying that Optum is requesting medical records on Molina's behalf (Remit Remark Code M127).

EOP message references each line selected for review and directs questions to Optum.

ALL of the following

Required records may include: history & physical, office/treatment records, consultation reports, operative reports, anesthesia and recovery room records, discharge summaries when applicable.
Additional applicable documentation: infusion flow sheets/medication administration logs; orders and results of diagnostic tests (pathology, radiology, laboratory); for DME, member signed receipt; for drugs, NDC, drug name, units, provider HRSA grant info and invoice with acquisition cost; itemization of services billed.
Submission methods accepted: secure internet upload, fax, or U.S. Mail (addresses and fax number provided).

Optum reviews submitted records to verify coding and extent/nature of services; this review is for coding/payment accuracy and does not determine medical necessity.

Optum will review records within 10 business days of receipt.

Review outcomes

If the claim is supported by documentation, Optum mails a notification and the claim is reprocessed for payment.
If the claim is partially supported, Optum mails a letter with rationale and the claim is reprocessed (with partial payment) or adjusted.
If the claim is unsupported, Optum mails a letter with rationale and the claim may be denied.

If records are not received, the review is performed based on available information and a technical denial letter may be issued; instructions for reconsideration/first level dispute are provided.

Providers may submit reconsiderations or first level disputes with supporting documentation within timely filing guidelines.

Additional actions

Aberrant billing patterns or potentially fraudulent behavior may be referred to Molina's Special Investigations Unit (SIU) for internal investigation.
Submission of medical records is not a guarantee of payment; Molina edits and contractual rules apply.

Coding Guidance and Disclaimer

Coding guidance and disclaimermixed

Coding disclaimer: codes listed in this policy are for reference purposes only and may not be all-inclusive. Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement. Listing of a service or device code in this policy does guarantee coverage. Coverage is determined by the benefit document. Molina adheres to Current Procedural Terminology (CPT®), a registered trademark of the American Medical Association (AMA). All CPT codes and descriptions are copyrighted by the AMA; this information is included for informational purposes only. Providers and facilities are expected to utilize industry standard coding practices for all submissions. When improper billing and coding is not followed, Molina has the right to reject/deny the claim and recover claim payment(s). Due to changing industry practices, Molina reserves the right to revise this policy as needed.

Provider Responsibilities and Appeals

Documentation Required

Medical record request and submission

Optum will request medical records on Molina's behalf. The EOP will include Remit Remark Code M127 with instructions and the allowed timeframe for record submission is based on Molina's timely filing requirements. Optum issues an initial request letter and, if applicable, a reminder. Providers must submit complete medical records to support the services billed; submission methods include secure electronic upload, fax, or U.S. mail. Optum will review records within 10 business days of receipt; submission does not guarantee payment.

Complete medical records (history & physical, office/treatment notes, consults, operative reports, anesthesia/recovery, discharge summaries)
Infusion flow sheets or medication administration logs, if applicable
Orders and results of diagnostic tests (pathology, radiology, lab), if applicable
DME: signed member receipt verifying device/equipment/supplies, if applicable
Drug codes: include NDC, drug name, units, provider HRSA grant info, and acquisition cost invoice
Itemization of services billed for the dates in question
Submission options: secure upload (https://sftp.databankimx.com/form/RecordUploadService), FAX 267-687-0994, or mail/delivery to Optum on behalf of Molina Healthcare (addresses provided in request letter)

Denial Risk

Denial risk and dispute process

If medical records are not received, Optum will perform the review based on available information and a technical denial may be issued. The denial letter will include instructions for submitting a reconsideration and/or a first-level dispute. Providers who disagree with a denial must submit an explanation of disagreement plus supporting documentation within timely filing guidelines.

Failure to submit records can result in a technical denial
Reconsideration/first-level dispute requests must include explanatory reason and any additional medical records or source documentation
Follow the timely filing requirements noted on the EOP/remit remark

Note

Second level disputes

If the Optum first-level dispute decision includes instructions for a second level dispute, providers should follow the directions in that letter. Note that Optum does not perform second-level disputes; any second-level dispute process and adjudication instructions will be provided in the first-level findings letter and all Optum communications are shared with Molina Healthcare for record retention.

Second-level dispute instructions (if applicable) are included only in the Optum first-level findings letter
Optum does not perform second-level disputes — follow Molina’s process as directed in the letter
All Optum communications are forwarded to Molina Healthcare for record retention

Prior Authorization

Pre-payment review and fraud referral

Optum’s pre-payment review may include coding accuracy checks and identification of aberrant billing patterns. Suspected fraud or abuse may be referred to Molina’s Special Investigations Unit (SIU) for further investigation. The review verifies coding and documentation consistency but does not determine medical necessity.

Optum may review records for coding accuracy prior to payment determination
Referrals of potential fraud/abuse will be made to SIU for investigation
Pre-payment review supports Molina’s payment integrity and FWA contractual obligations

OpenPayer

Optum Pause & Pay payment accuracy solution

Pre-payment Review Criteria

Coding Guidance and Disclaimer

Provider Responsibilities and Appeals

Definitions