Optum Comprehensive Payment Integrity (CPI)
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Defines the Optum CPI system used to edit and review facility and professional claims for payment integrity, including pre-pay and post-pay claim edits, documentation requests, and referral to investigations; affects providers submitting claims to the Health Plan.
No material clinical or coverage changes in this revision.
Claims Review and Payment Determinations
Claims review and documentation-based payment determination
Claims are reviewed for payment integrity; decisions are based on whether submitted documentation supports billed services (not on medical necessity).
Escalation
- Aberrant billing patterns or potentially fraudulent behavior may be referred to the Special Investigations Unit (SIU) for internal investigation as part of FWA response.
- If a claim line is denied, providers will receive a detailed letter from Optum explaining why the services billed were not supported by the medical records.
Coding and Timeframes
| No codes listed |
Provider Responsibilities and Support
Submit requested medical records to the address in the request within 30 calendar days
When Optum requests medical records to support billed services, providers must submit adequate medical record documentation that supports the services billed to the address in the medical record request letter within 30 calendar days. If records are not received, Optum will determine the claim based on available information, which may result in the denial being upheld. Specific provider contract time frames may apply.
- Submit records to the address specified in the medical record request letter.
- Respond within 30 calendar days unless a different contract timeframe applies.
- Understand that submission of records does not guarantee payment; decisions are based on whether documentation supports how the claim was billed.
Use the two-level dispute process: Optum (first level) then Centene (second level)
Providers have dispute rights on all claim denials. For the CPI program, Optum performs the first-level dispute review and Centene handles second-level disputes.
- Initiate first-level disputes through Optum CPI per the instructions in the denial communication.
- Escalate second-level disputes to Centene as outlined in the plan's dispute instructions.
Contact Optum PIRT for program questions and record-submission guidance
For program questions or guidance on submitting records, providers may contact Optum's Provider Inquiry Response Team (PIRT). PIRT can educate providers on submitting medical records for initial review or for dispute questions.
- Call PIRT at 1-877-564-7503.
- PIRT hours: Monday–Friday, 8:00 a.m. to 6:30 p.m. Central Standard Time (excluding holidays).
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.