Partnering with Optum (All Products)

As required by State and Federal governing entities, Buckeye Health Plan is committed to continuously evaluating and improving overall Payment Integrity solutions. We have partnered with Optum who is supporting us in performing prepayment claim reviews. The purpose of this review is to verify the extent and nature of services rendered for the patient’s condition and claims are coded correctly for services billed. 

Optum’s edits will be implemented in phases and are not applied as a blanket “rule” for all claims.  This will be implemented for all lines of business – Medicaid, Medicare and Marketplace products.

Only a small number of claims that meet the criteria will be chosen for review.  Providers may experience a slight increase in written requests for medical record submission prior to payment.  These requests will come from Optum and will contain instructions for providing the documentation.  Should the requested documents not be returned, the claim(s) may be denied.  Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to partnering with you to provide the highest quality care for your patients/our members.