Optum to provide enhanced prospective claim editing for Blue Cross commercial claims

Starting in November 2021, Blue Cross Blue Shield of Michigan will begin working with Optum, a data, analytics and consulting group, for enhanced prospective claim editing for services provided to our commercial members. We anticipate that this change will help promote correct coding and support payment accuracy.

At Blue Cross, we’re committed to implementing payment integrity solutions and will begin performing enhanced prepayment claim reviews with the help of Optum. As a result, health care providers may be asked for medical records and billing documents that support the charges billed.

The prepayment claim reviews will apply to professional, outpatient facility and inpatient facility claim types. The reviews will look for any overutilization of services or other practices that directly or indirectly result in unnecessary costs.

Detailed instructions on how to submit medical records will be included in each Optum medical record request letter. Providers who don’t submit the requested documentation in the allocated time frame may receive a payment denial until all information necessary to adjudicate the claim is received.

If medical records received don’t support the billed service, the service will be denied. If medical records received support the claims, the claims will automatically be processed for payment without the need for them to be resubmitted. As outlined in your contracts with us, providers retain their right to dispute results of reviews.

Unique clinical editing reason codes will appear on the 835 response files or provider vouchers. Over the coming months, you’ll receive additional details about this program.

As a reminder, when billing Blue Cross commercial claims, you should follow guidelines from:

• The American Medical Association’s Current Procedural Terminology, or CPT, code set regarding:
• Correct modifier usage
• Evaluation and Management reporting guidelines
• National bundling edits
• National specialty societies, such as:
• American College of Surgeons
• American College of Radiology
• American Association of Neuromuscular and Electrodiagnostic Medicine
• American Cancer Society

As part of your contract with us, health care providers affiliated with our PPO commercial network agree to supply services to Blue Cross members and bill according to guidelines and requirements set by the American Medical Association and select specialty societies.

If you have questions about the Blue Cross claim editing process, contact Provider Inquiry. Professional providers should call 1‑800‑344‑8525, while facility providers should call 1‑800‑249‑5103.