Medicare AdvantageDocumentationHigh impact
Optum Payment Integrity Phase 1: Effective September 1, 2026
Ambetter·KS · Orthopedics, Physical Therapy, Pain Management·Claims & Billing
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 reviews for high-dollar IV hydration therapy and custom fitted/fabricated prosthetics or orthotics across Medicare Advantage, Marketplace, and Commercial plans. Providers must submit requested documentation promptly or claims will be denied; disputes can be filed directly with Optum.
Action Required
By September 1, 2026: Billing and clinical teams must establish a process to respond promptly to medical record requests from Optum for IV hydration therapy claims and custom DME (prosthetics/orthotics) claims. Designate staff to monitor for incoming documentation requests, ensure medical records are compiled and submitted within required timeframes to prevent claim denials. Update internal workflows to flag high-dollar IV hydration and custom DME claims for potential prepayment review. Establish a dispute resolution process for claims denied due to documentation inadequacy or coding concerns. Contact Provider Relations at 1-844-518-9505 (Marketplace) or applicable WellCare numbers (Medicare Advantage) to clarify submission procedures and timelines.