Reminder: Additional edits coming soon for Blue Cross commercial claims, including medical record requests from Optum

In support of our commitment to payment integrity solutions that support payment accuracy and encourage correct coding, Blue Cross Blue Shield of Michigan is working with Optum, an independent company, to identify claims that may require additional review.

In previous articles, we let you know about edits that will occur through our new relationship with Optum. You may occasionally receive a letter directly from Optum requesting medical records before claim payment. We expect this to happen for no more that 1% of claims.

Here are some answers to frequently asked questions:

Q: How does Optum decide which claims require medical record review?

A: Optum has developed customized analytics to identify claims that need additional review. These analytics are developed using Blue Cross’ internal payment policies and the policies of external agencies (e.g., the Centers for Medicare & Medicaid Services).

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

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

• A list of affected claims
• An itemized list of required documents
• A page of instructions on how to submit through a secure internet portal (or by hard copy), plus a cover sheet with a bar code to identify your case number and pertinent information for Optum.  

Medical records should 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.     

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

A: Contact Optum directly at the phone number listed in the medical record request letter.        

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

A: Optum’s initial findings denial letter will include information you’ll need to request a reconsideration. 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

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