CurrentWellCarePolicy CPP-136

Optum Comprehensive Payment Integrity (CPI)

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Defines Centene/WellCare's use of the Optum CPI system to perform pre-pay and post-pay automated claim edits and medical record reviews for facility and professional claims as part of Fraud, Waste, and Abuse (FWA) activities, and describes provider responsibilities and dispute rights.

Policy Summary

PayerWellCare

PolicyOptum Comprehensive Payment Integrity (CPI)

Policy CodePolicy CPP-136

Change TypeNo material changes

Effective DateJul 9, 2018

Last ReviewOct 25, 2022

Next Review DateOct 25, 2022

Key ActionProviders must submit adequate medical records in response to Optum medical record requests, typically within 30 calendar days, to support billed services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30medical record submission days

7 business daysOptum review time

120 daysdenial if no records

1-844-458-6739provider contact

Coverage and Policy Application

Coverage and coding review stance

Optum CPI edits claims to determine proper coding and payment; adjustments do not equate to member noncoverage and providers must not bill members for payment reductions resulting from edits.

Centene uses claims editing software (Optum CPI) to assist in determining proper coding for provider claims payment; the software applies industry-standard coding criteria (e.g., NCCI, NPFS, AMA, specialty society guidelines) and state-specific regulations.

Optum CPI may result in claim edits for specific procedure code combinations that may lead to payment adjustments, denials, or requests for medical record review pre- or post-payment.

Providers may request reconsideration of any adjustments produced by the claims editing software by submitting a timely request to Centene or a contracted third-party vendor.

A reduction in payment as a result of claim policies and/or processing procedures is not an indication that the service provided is a non-covered service; providers must not bill or collect payment from members for such reductions in payment.

All ICD-10-CM, CPT, HCPCS, and DRG codes are eligible for claims editing as described; coding information is for informational purposes and inclusion/omission of codes does not imply coverage or reimbursement.

If medical records are requested, providers should submit adequate documentation that supports the billed services, typically within 30 calendar days; once received, Optum reviews records (within 7 business days) and will recommend pay or deny based on whether documentation supports how the claim is billed (not clinical medical necessity).

General coverage and application statements

General terms governing application of the payment policy and precedence of other regulations:

Coverage and payment determinations and administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, policy, contract) and to applicable state and federal requirements.

This payment policy is a guide to payment and does not constitute a contract, guarantee of payment, or medical advice; providers remain responsible for medical judgment and treatment decisions.

Health Plan may change, amend, or withdraw this payment policy at any time; the posting date may differ from the effective date, and applicable legal or regulatory requirements govern if there is a discrepancy.

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

For Medicare members, applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this payment policy's criteria.

This payment policy is proprietary to Centene Corporation; unauthorized copying, use, or distribution is strictly prohibited.

Codes Subject to CPI Editing

Codes subject to CPI editingmixed

All ICD-10-CM, CPT, HCPCS, DRG

All listed code sets are eligible for claims editing as described.

Provider Responsibilities, Timelines, and Disputes

Documentation Required

Medical record submission and timelines

Providers will receive a medical records request (MRR) letter from Optum that includes directions on how or where to submit the records. Providers are expected to submit adequate medical record documentation to support billed services, typically within 30 calendar days; Optum will send a follow-up reminder if no response. Optum reviews received records within 7 business days and may deny billed code(s) based on the documentation; if records are not received, Optum may determine the claim based on available information which can result in a denial upheld as a technical denial after 120 calendar days. Providers may still submit records after a technical denial for subsequent review.

Initial MRR letter lists claims and provides submission instructions (one letter if multiple claims flagged the same day).
Respond within 30 calendar days to avoid follow-up reminders; records not received within 120 calendar days result in a denial letter.
Optum reviews records within 7 business days of receipt; submission does not guarantee payment.

Denial Risk

Dispute rights and process (first and second level)

Providers have the right to dispute denials; Optum conducts the first-level dispute and Centene handles second-level disputes per the health plan's Quick Reference Guide (QRG). When a provider submits a dispute, Optum will acknowledge receipt and send a dispute response letter with outcome and instructions for submitting a second-level dispute to Centene.

If at least one line on a claim is denied after record review, Optum will issue a denial letter explaining rationale and first-level dispute instructions.
Follow QRG instructions for submitting second-level disputes to Centene after receiving Optum's dispute response letter.

Documentation Required

Policy governance, applicability, and change rights

Health Plan may change, amend, or withdraw this payment policy at any time; coverage and payment determinations are subject to all terms, conditions, exclusions and limitations of the coverage documents and applicable state and federal requirements. The posted date may differ from the effective date and legal/regulatory requirements govern in case of discrepancy.

The payment policy is a guide to payment, not a contract or guarantee of payment.
Health Plan retains the right to develop and adopt additional payment policies as needed.

Terms and Definitions

Optum CPI and related terms

DefinitionOptum CPI: an automated system that applies systematic algorithms and industry-standard coding criteria (e.g., NCCI, NPFS, AMA, specialty society guidelines) to identify aberrant billing patterns, may deny claims, and may request medical records to support billed services.

Scope of reviewsPerforms claim editing on both pre-pay and post-pay bases as part of Centene's Fraud, Waste, and Abuse (FWA) program; may refer suspected fraud to the Special Investigations Unit (SIU).

Specialized medical reviewsClaims may be reviewed by board-certified physicians for coding accuracy; reviewers maintain role-appropriate certifications/credentials.

Deliverables to providersOptum may issue Explanation of Payment (EOP) letters and medical record requests (MRRs) to providers indicating paid, denied, or adjusted claims and required documentation.

Related terms includedPolicy defines related terms such as Fraud, Waste, Abuse, Turnaround Time (TAT), Specialized Medical Reviews, and Explanation of Payment.

Health Plan

Definition'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 affiliate.

Policy effectThis payment policy is a guide to payment and is not a contract or guarantee of payment; coverage and payment determinations are subject to terms, conditions, exclusions and limitations of coverage documents and applicable law.

Change authorityHealth Plan retains the right to change, amend or withdraw this payment policy at any time; effective date is determined by Health Plan and posting date may differ.

Legal precedenceIf discrepancies exist between this payment policy and legal/regulatory requirements, law and regulation govern.

Providers

DefinitionProviders are independent contractors who exercise independent professional medical judgment and are not agents or employees of Health Plan.

Responsibility for careProviders are solely responsible for medical advice and treatment decisions for members; the payment policy does not constitute medical advice or dictate treatment.

Contractual bindingProviders, members and representatives are bound by the terms of this payment policy through existing contracts or by providing services or submitting claims when no contract exists.

Prohibition on copyingThis payment policy is the property of Centene Corporation; unauthorized copying, use, or distribution is strictly prohibited.

Policy Summary

PayerWellCare

PolicyOptum Comprehensive Payment Integrity (CPI)

Policy CodePolicy CPP-136

Change TypeNo material changes

Effective DateJul 9, 2018

Last ReviewOct 25, 2022

Next Review DateOct 25, 2022

Key ActionProviders must submit adequate medical records in response to Optum medical record requests, typically within 30 calendar days, to support billed services.

SourceLink

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Optum Comprehensive Payment Integrity (CPI)

Customize your policy alerts

Sign up for WellCare Policy CPP-136 alerts

Get alerted when Policy CPP-136 changes without checking for updates manually.

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Coverage and Policy Application

Coverage and coding review stance

Optum CPI edits claims to determine proper coding and payment; adjustments do not equate to member noncoverage and providers must not bill members for payment reductions resulting from edits.

Optum CPI may result in claim edits for specific procedure code combinations that may lead to payment adjustments, denials, or requests for medical record review pre- or post-payment.

Providers may request reconsideration of any adjustments produced by the claims editing software by submitting a timely request to Centene or a contracted third-party vendor.

General coverage and application statements

General terms governing application of the payment policy and precedence of other regulations:

This payment policy is a guide to payment and does not constitute a contract, guarantee of payment, or medical advice; providers remain responsible for medical judgment and treatment decisions.

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

For Medicare members, applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this payment policy's criteria.

This payment policy is proprietary to Centene Corporation; unauthorized copying, use, or distribution is strictly prohibited.

Provider Responsibilities, Timelines, and Disputes

Documentation Required

Medical record submission and timelines

Initial MRR letter lists claims and provides submission instructions (one letter if multiple claims flagged the same day).
Respond within 30 calendar days to avoid follow-up reminders; records not received within 120 calendar days result in a denial letter.
Optum reviews records within 7 business days of receipt; submission does not guarantee payment.

Denial Risk

Dispute rights and process (first and second level)

If at least one line on a claim is denied after record review, Optum will issue a denial letter explaining rationale and first-level dispute instructions.
Follow QRG instructions for submitting second-level disputes to Centene after receiving Optum's dispute response letter.

Documentation Required

Policy governance, applicability, and change rights

The payment policy is a guide to payment, not a contract or guarantee of payment.
Health Plan retains the right to develop and adopt additional payment policies as needed.

Terms and Definitions

Optum CPI and related terms

Specialized medical reviewsClaims may be reviewed by board-certified physicians for coding accuracy; reviewers maintain role-appropriate certifications/credentials.

Deliverables to providersOptum may issue Explanation of Payment (EOP) letters and medical record requests (MRRs) to providers indicating paid, denied, or adjusted claims and required documentation.

Related terms includedPolicy defines related terms such as Fraud, Waste, Abuse, Turnaround Time (TAT), Specialized Medical Reviews, and Explanation of Payment.

Health Plan

Definition'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 affiliate.

Change authorityHealth Plan retains the right to change, amend or withdraw this payment policy at any time; effective date is determined by Health Plan and posting date may differ.

Legal precedenceIf discrepancies exist between this payment policy and legal/regulatory requirements, law and regulation govern.

Providers

DefinitionProviders are independent contractors who exercise independent professional medical judgment and are not agents or employees of Health Plan.

Responsibility for careProviders are solely responsible for medical advice and treatment decisions for members; the payment policy does not constitute medical advice or dictate treatment.

Prohibition on copyingThis payment policy is the property of Centene Corporation; unauthorized copying, use, or distribution is strictly prohibited.