Medicare AdvantageDocumentationHigh impact
Optum Payment Integrity - Professional Claims for Select Surgical Procedures: Effective September 1, 2026
Ambetter·KS · General Surgery, Cardiothoracic Surgery, Orthopedics +7 more·Claims & Billing
Effective date
Sep 1, 2026
We identified it
Aug 26, 2026
Summary
Effective September 1, 2026, Optum (partnered with Sunflower Health Plan) will implement prepayment medical record review for select surgical procedures on professional claims across Medicare Advantage, Marketplace, and Commercial plans. Billing teams should expect increased written requests for medical record submission prior to payment authorization. Claims without timely documentation submission will be denied, and providers may dispute findings directly with Optum.
Action Required
By August 31, 2026: (1) Billing team must establish a process to track and respond to prepayment medical record requests from Optum within required timeframes to prevent claim denials. (2) Educate all providers and clinical staff that Optum will request physician clinical notes for select surgical procedures to verify service documentation matches billing. (3) Update claim submission procedures to anticipate delays while prepayment review is completed. (4) Establish internal documentation of denied claims due to non-response, and implement a dispute resolution workflow for appealing Optum's findings through their direct dispute process. (5) Identify point person(s) for managing Optum communications and contact Optum at the numbers provided (Ambetter Marketplace: 1-844-518-9505; WellCare Medicare Advantage HMO: 1-800-977-7522; D-SNP: 1-844-796-6811) to clarify which specific surgical procedures trigger this review.