Optum Comprehensive Payment Integrity (CPI) Policy

Date: 03/22/23

Effective May 1, 2023

MHS Health Wisconsin is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse.

This is a notification that we will begin performing additional prepayment claim reviews, effective May 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.

MHS Health utilizes widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers. These prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. 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.

Review the Optum Comprehensive Payment Integrity (CPI) policy (PDF)

Thank you for your partnership as we work together to achieve our shared goal of delivering quality, affordable, and comprehensive healthcare to our members.

If you have any questions, please contact our Provider Services team at 1-800-222-9831.