All PlansDocumentationHigh impact
Update on medical record review programs
Harvard Pilgrim Health Care·Reimbursement
Effective date
Nov 1, 2025
We identified it
Jun 26, 2026
Summary
Point32Health is transitioning medical record review programs for Tufts Health Plan products to Optum, effective November 1, 2025. Providers will receive requests from Optum for medical records and billing documents to verify accurate coding, documentation, and compliance. Documentation must include provider orders supporting all charges and clinical documentation supporting diagnoses and billed services.
Action Required
Before November 1, 2025: (1) Billing team must establish internal processes to manage Optum medical record review requests, including tracking submission deadlines and ensuring timely responses. (2) Implement workflow to verify that ALL claims contain provider orders in medical records supporting charges and clinical documentation supporting diagnoses and services billed—conduct audit of current documentation practices now. (3) Designate staff to receive Optum review letters and assign responsibility for organizing and submitting requested documentation via secure portal, mail, or fax within the timeframe specified by Optum. (4) Brief providers on documentation requirements, emphasizing that missing provider orders or insufficient clinical documentation will result in claim denials. (5) Establish appeal submission process per Optum's instructions included in determination letters. Failure to respond to Optum requests within specified timeframes will result in claim denials. This applies to all Tufts Health Plan products under Point32Health effective Nov 1, 2025.