Optums Comprehensive Payment Integrity (CPI) tool

Date: 03/31/23

Thank you for your continued partnership with Ambetter from WellCare of New Jersey. We are committed to continuously improving our overall payment integrity solutions to prevent overpayments due to waste or abuse. We utilize widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers.

This is a notification that we will begin performing additional prepayment claim reviews on May 1, 2023 using Optum’s Comprehensive Payment Integrity (CPI) tool. These reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs.

As a result of these reviews, providers may be asked for medical records and billing documents that support the charges billed. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.

The provider will receive detailed instructions about how to submit the requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.

If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews.

Summary of Policy:

We thank you for your commitment to the care and wellbeing of our members and to the communities we serve.  Should you have any questions or concerns about this notification, please contact us at Provider Services 1-844-606-1926. Policies are posted on our website at https://ambetter.wellcarenewjersey.com