Medicare AdvantageDocumentationHigh impact
Optum Payment Integrity - Critical Care Coding: Effective September 1, 2026
Ambetter·KS · Critical Care·Coding
Effective date
Sep 1, 2026
We identified it
Aug 26, 2026
Summary
Effective September 1, 2026, Sunflower Health Plan (through Optum) will implement prepayment medical record review for critical care coding claims to verify appropriate billing and documentation. Providers will receive increased written requests for medical record submission before payment; failure to return requested documentation will result in claim denials.
Action Required
By August 31, 2026: Billing team must establish a process to track and respond to medical record requests from Optum for critical care coding claims. Train all billing and clinical staff to prioritize these requests and submit documentation within the timeframe specified by Optum to avoid claim denials. Notify providers to ensure clinical notes for critical care patients contain detailed documentation of services rendered and medical decision-making. Establish internal tracking system to monitor response deadlines and denial appeals. Update claim denial procedures to reference EX code EXbo for documentation-related denials and establish dispute resolution workflow with Optum.