Reminder: Additional edits coming in December for Blue Cross commercial claims

At Blue Cross Blue Shield of Michigan, we remain committed to payment integrity solutions that support payment accuracy and encourage correct coding. In support of that commitment, you’ll begin to see new edits starting in December.

In the August 2021 Record, we let you know about edits that will occur through our new partnership with Optum. The Optum program has two components related to pre-payment edits and medical record requests.

You’ll be able to recognize the edits by the unique provider message codes (K500-K544). In some instances, you may receive a letter requesting medical records directly from Optum prior to claim payment. We expect these requests to occur for no more that 1% of claims.

Here are some answers to frequently asked questions about medical records requests that may be helpful:

How does Optum decide which claims require medical record review?

Optum develops customized analytics that are used to identify claims that need additional review. These analytic concepts are developed using Blue Cross Blue Shield of Michigan’s internal payment policies and policies from external agencies, such as the Centers for Medicare & Medicaid Services, as applicable.

How do I submit my medical records and what should I include?

The Optum medical record request letters will be sent within two business days of a  claim being selected for review (referred to as tagging). The request letters will provide detailed instructions of how and where to submit your medical records and what to include with your submission. This includes:

• A list of impacted claims
• An itemized list of required documents
• A page of instructions to submit via secure internet portal or hard copy, plus a cover sheet with a bar code to identify your case number and pertinent information for Optum  

Medical records must be submitted within 60 calendar days of the request. Once received, records will be reviewed within 12 business days and an outcome letter will be sent to you.  

If no records are received within 60 days, a technical denial letter will be sent as final communication, and Blue Cross will be notified that Optum has closed the case.     

When the program starts, whom do I contact at Optum for assistance with medical record submission?

If you need assistance with submitting your medical records or have any questions, you’ll be able to contact Optum directly at the phone number provided in the medical record request letter.

What options do I have if I don’t agree with a denial?

When Optum sends its initial findings denial letter, it will include information required if you request a reconsideration of the review. Your information should include:

• The cover sheet provided with the denial letter with a bar code
• Explanation of why you don’t agree with the denial
• Supporting documentation, such as additional medical records or source information

As a reminder, Optum will conduct its review and send a resolution letter within 12 business days from date of receipt. Timely filing rules will apply.