Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. On average, we save $110K over the lifetime of a claim simply by doing what we do best with our early-intervention program. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Log in and click on the ALERT tab. The peer physician will attempt to obtain verbal or written clarification of the agreed upon current and/or future treatment recommendations. CONDITIONAL PAYMENT MANAGEMENT AND MONITORING. Total records not to exceed one hundred TIN records. We focus on timely and accurate reporting information to Medicare. Our original network, the Optum Transplant Centers of Excellence network, was developed in 1986 and has grown to be the largest network of its kind in the world, managing more than 14,000 transplant referrals in 2013. Beginning January 1, you must complete and submit the Reimbursement Claim Form within three months, and submit any appeal along with additional documentation within 60 days. Optum will then contact the claim handler and provide the appropriate recommendation. Click to see a sample 1500 form, a listing of all Optum required fields, as well as the reverse side of the 1500 Claim Form. Finally, a cross functional team reviews all aspects of the case to project future care spending for the MSA, and by not waiting until the time of settlement to implement these recommendations, we also avoid delaying claim resolution. Medical Services: Bill Review / Clinical & Coding Logic | PPO | Clinical Case Management, Brand alternative to opioid-induced constipation medication Amitiza® (lubiprostone) arrives to market, Significant medication average wholesale price decreases for WCMSAs, New law requires CMS to provide information on Medicare plan type(s) to workers’ comp, no-fault and liability insurers, CMS is moving toward Civil Money Penalties for improper reporting, Strict application of off label prescription use, Weaning of medications and age-related prescription drug contraindications and dosage requirements, Brand alternatives and patent expirations, Industry standards of care (American College of Occupational and Environmental Medicine (ACOEM), Evidence Based Medicine (EBM), Official Disability Guidelines (ODG)). Through Optum Bank, ... Use a separate claim form for each person for whom you are filing a claim. Utah (UT) CONDITIONAL PAYMENT APPEAL SERVICES TIER 2. *Note: A clinician number will be pre-populated on the form. Our legal compliance team is dedicated to proactively resolve Conditional Payment matters for you. Medicare allows for the opportunity to initiate the formal appeal process by requesting a redetermination and reconsideration. Optum’s MSA allocation is the lowest defensible MSA in the industry. Important note: Most forms on this page are in PDF formatting, unless otherwise noted. If no Conditional Payment activity found, Optum will establish the file with the BCRC and provide notification to the claim handler of the establishment of the case and any associated notices that are received as a result. Optum will then notify the adjuster in writing of any disputable charges and provide recommendations for payment and/or reduction of the Conditional Payments amount. Notice how Optum pulls it all together. Therapeutic changes are validated by monthly file reviews with case re-evaluation at the end of six months. The primary treating physician’s office is contacted before and after the claimant’s scheduled appointments, encouraging compliance. Upon receipt of a case assignment accompanied by a Social Security Release form, Optum will obtain Social Security Disability and Medicare status with the SSA. Enrollment Form - Retiree/LTD 2021 Medicare PDP Enrollment Form VibrantRx - Retiree 2021; Retiree Appeal Form 2021; COBRA. related issues. All of these companies use the same Payer ID to file claims (87726), so they all end up in the same place at the end of the day. The World Trade Center (WTC) Health Program is a federal program that provides monitoring and treatment for certified WTC-related health conditions for eligible Responders to the September 11, 2001 attacks in New York City (NYC), the Pentagon in Arlington, Virginia, and the … California (CA) Information and personal contact information will be securely transmitted directly to MTM and will be kept confidential to the extent required by HIPAA. Auto No-Fault After the analysis of the Conditional Payment demand is complete and it is determined that there are unrelated items included in the amount, Optum will obtain supporting documents, draft and file an agreement disputing the unrelated changes in order to reduce the total Conditional Payments amount. When provided with the appropriate authorization forms, Optum will engage with the Department of Treasury to request a list of claims currently in collections and heading to possible offset for each requested Tax ID. Pennsylvania (PA), Puerto Rico (PR) By working with strategic partners Optum leverages public databases to validate the five key data elements to be able to accurately query, identify or determine Medicare eligibility status, and report a claim for Section 111. Our services are available individually, grouped together or often sought out in a complete package for an end-to-end solution. Outreach is made based on the state’s ex parte rules. Ancillary Services Vermont (VT) It is advised to download each Wellness Assessment rather than copy because photocopying will deteriorate the face quality of the form which could lead to technical difficulties in the ability of Optum to read the forms when you fax them to us. Massachusetts (MA) If Conditional Payment verification is requested, upon receipt of authorized forms, Optum will correspond with the Benefit Coordination and Recovery Contractor (BCRC) to determine if Conditional Payments exist. ... You have the right to appeal that decision. UnitedHealthcare is here to help providers who may need information, service or support on network management, provider contracting and more. We have consistently achieved a CMS (Centers for Medicare & Medicaid Services) first pass acceptance rate of 81 percent. Outreach is made based on the state’s ex parte rules. If services require signed authorization, either by the claimant or the Registered Reporting Agent (RRE), then Optum will prepare and secure the necessary documentation from the appropriate party at the request of the adjuster. Optum is an equal opportunity employer. This type of MSA may result in a lower allocation amount than a CMS-approved MSA. Maine (ME) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Idaho (ID), Illinois (IL) Performing a clinical review earlier in the life of a claim leads to a significant positive impact on the overall cost of the claim, without sacrificing the claimant’s care or Medicare Secondary Payer (MSP) compliance status. CMS CONDITIONAL PAYMENT REFUND CHECK SERVICES. Appeals at the Administrative Law Judge, review by the Medicare Appeals Council, and United States federal court action level are handled solely by our dedicated MSP Legal team. Alaska (AK) Visit the COBRA tab; ENROLLMENT FORMS AND GUIDES | 2020. Pharmacy Care Services For faster claims reminbursement with less hassle, it is strongly encouraged that you sign up for electronic funds transfer (EFT) via our Electronic Payments & Statements (EPS) here . Assistance with triaging a case for possible mitigation, review of appropriateness and necessity on the claim. Wisconsin (WI) Upon the completion of a successful appeal, funds that have been taken as an offset by the Department of Treasury may be repaid. Although there is no formal appeals process for a reconsideration of an approved MSA, CMS will re-review a file if additional evidence that pre-dates the date of the initial submission is provided. CONDITIONAL PAYMENT APPEAL SERVICES TIER 1. Optum’s cross-disciplinary expertise in pharmacy, medical, legal and claims allows us to effectively combine medical and pharmaceutical standards of care, cost effective pricing, as well as application of the distinct legal facets of each liability case. Washington (WA) FCM services can be used in conjunction with Peer Outreach and Nurse Progress Monitoring services to provide the opportunity for an in person visit to facilitate treating physician cooperation with this process, when needed. Please ensure you have the latest version of Adobe Reader on your system. This is due to the MSA being case specific and allocated based on medical records, pharmacy history, utilizing the CMS WCMSA Reference Guide until it deviates from known clinical concerns, state statutory or jurisdictional nuances, and/or includes items and services not otherwise reimbursable by Medicare. Clinical pharmacists perform a Medication Analysis while clinical nurses, trained in CMS guidelines, review treatment records evaluating all aspects of medical treatment including Durable Medical Equipment (DME), surgeries, home health care, diagnostics and supplies. Next, we utilize our peer-to-peer outreach and nurse monitoring to review therapies which could prevent the claim from settling altogether. As a result, we have identified and implemented an additional $15.3 million in savings for our clients while preparing MSA allocations. Texas (TX) We use database script to update recovery agent fields prior to each submission to CMS to ensure any recovery related mail is directed to the proper location for handling in addition to the RRE address. South Dakota (SD) When refunds are owed from the Treasury or Medicare, Optum will act as the point of contact for management, providing tracking and delivery of checks to a designated client contact person and address. Revisions are charged at the WC MSA and LMSA Revision rates. In conjunction with the Conditional Payment Letter Forwarding process, Optum will also monitor Conditional Payment due dates, send follow-up notices and provide reports tracking the status of the demand. West Virginia (WV) Note: Non-complex sweeps encompass a single RRE ID and data from a single third-party reporting agent (TPRA) or TPA. An independent medical summary that considers future medical treatments for the claim under review. United Health Care (UHC), Optum, and United Behavioral Health (UBH) are all “Optum” companies which handle mental health claims. Login Kentucky (KY) Optum considers: The treatment of myofascial structures using manual therapy techniques in the same organ (spine), where CMT was performed and was contiguous (cervical and thoracic), does not constitute treatment of different anatomic sites. For paper claim submission, facilities should use the industry standard UB-04 claim form using contracted revenue codes. Optum offers assistance for claimants who are willing and able to self-administer their MSA account. Maryland (MD) To file an appeal or grievance for your medical benefit coverage or your prescription drug coverage, contact Keystone 65 Customer Service at 1-800-645-3965 or Personal Choice 65 Customer Service at 1-888-718-3333; TTY/TDD users should call 711, 7 days a week, 8 a.m. to 8 p.m.; or you can complete and submit online the Request for Medicare Prescription Drug Coverage Determination or … Upon receipt of detailed pharmacy transactions, a list of claims will be provided to the client that meets certain criteria, which may indicate potential prescription drug concerns or high prescription drug usage. Tennessee (TN) North Dakota (ND) Following written confirmation of treatment, the MSA allocation can be adjusted. New Mexico (NM) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Kansas (KS) EncoderPro.com Professional is an online, real-time code look-up application that delivers a higher degree of code detail and reference information on CPT ®, HCPCS Level II, and both ICD-9-CM and ICD-10-CM and PCS codes.Monthly automatic code updates throughout the year will help practices that bill Medicare Part B and private payers reduce rejected claims due to improper coding. Designed to help mitigate risk with CMS correspondence going to old addresses, Optum will update the RRE address, recovery agent address or both, on a previously reported claim. Wellness Assessments are also available at the secure transaction section of Provider Express for registered users! Georgia (GA) Outcomes are reviewed with the claims professional by a clinical nurse. Here you'll find phone numbers, addresses, emails and other contact information to help support providers. Federal Services. Active Employees - 2020. New Hampshire (NH) The MSA contains an analysis of the projected amounts based upon the lifetime rated age, is customer specific, and also includes a grid that lays out the non-Medicare covered costs, all within a written comprehensive report. Real Appeal is a free online weight loss program available to eligible employees and family members. A Non-Submit MSA may be selected in situations where the settlement does not meet the Centers for Medicare & Medicaid Services (CMS) Work Comp Medicare Set-Aside (WCMSA) review thresholds, or the settling parties have decided not to participate in the voluntary CMS MSA review process. North Carolina (NC) Optum recommends the use of the physician outreach for claims with high allocations following initiation of settlement process, where there are complex therapy concerns or the treating physician(s) prefer to discuss the case with a peer-level physician. Anything beyond two hours is an additional charge per 15-minute increment. Our dedicated Conditional Payments team will review the previous argument and response by Medicare and craft higher levels appeals to support the case through reconsideration. Upon receipt of a case assignment accompanied by a Social Security Release form, Optum will obtain Social Security Disability and Medicare status with the SSA. Notes about the Wellness Assessment forms: Alabama (AL) The FMCP estimates the future medical cost based on future medical needs, pre-existing injuries, and co-morbid conditions, including the life expectancy of the claimant. Minnesota (MN) Click here to learn where to submit Optum Claim forms. The following entities comprise the Optum Workers’ Compensation and Auto No-Fault  (OWCA) division: PMSI, LLC, dba Optum Workers’ Compensation Services of Florida; Progressive Medical, LLC, dba Optum Workers’ Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers’ Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; PMSI Settlement Solutions, LLC, dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Equian, LLC, collectively and individually referred as “Optum or OWCA. Optum encourages a review of the ICD codes, Ongoing Responsibility of Medical (ORM) and Total Payment Obligation to Claimant (TPOC) information provided through Section 111 mandatory insurer reporting, to ensure accurate reporting, as Medicare’s claims processing contractors will use this information to pay or deny medical bills accordingly. A comprehensive review of pharmacy history and medical treatments which identifies clinical recommendations for potential cost savings in multiple areas of a claim. Specialty-matched peer physician(s) collaboratively engage the treating physician to discuss all aspects of the case and determine alternative treatment strategies that are consistent with standards of care and facilitate implementation of recommended changes. Optum will assign a FCM to the case based on client approved triggers or authorization from the claim handler. Medical Services SECURING SIGNED RELEASES/AUTHORIZATION FORMS. New Jersey (NJ) Optum's Centers of Excellence networks are the gold standard in complex health care. This will alert adjusters to potential high exposure prescription drug issues that may require intervention. Optum has a full staff of experts that Our Self-Administration service includes unlimited phone and online support for all self-administration accounting needs, access to required forms, and repricing of medical bills for one year or more, depending on the level of assistance. Florida (FL) Mitigation opportunities are identified using evidence-based guidelines and an action plan to address therapeutic concerns and cost containment is provided. Optum will monitor claims that return a positive hit for Medicare Beneficiary status and review the case for current Conditional Payment actives for the associated date of injury. TAXPAYER IDENTIFICATION NUMBER (TIN) SMART SWEEP. Inpatient claims may be submitted through Electronic Data Interchange (EDI) through the clearinghouse of your choice. After this thorough review, a summary report is created detailing specific clinical recommendations to address therapeutic concerns regarding the claimant’s medication therapy as well as cost containment action plan. To receive copies of the 02/12 1500 Claim Form, contact: NJ Out-of-Network Inadvertent/Involuntary Claims Negotiation Request Form, NY State Out-of-Network Surprise Medical Bill Assignment of Benefits Form, Arizona Prior Authorization Request Process, ASAM Facility Daily Schedule of Activities (Coming soon). As an industry-leader in innovative and comprehensive solutions for MSP compliance, Optum delivers a customizable platform that provides tools and advanced reporting capabilitie for MIR through MedicareConnect. Form – Client Grievance or Appeal – CCHEA Outpatient 6-28-18 Vietnamese (docx) 2018-08-15: Form – Client Grievance or Appeal – JFS Residential 6-28-18 Arabic (docx) 2018-08-15: Form – Client Grievance or Appeal – JFS Residential 6-28-18 English (docx) For use after Jul 1 2018: 2018-06-29 Optum Forms - Claims All outpatient and EAP claims should be submitted electronically via Provider Express or EDI. Our experts can re-evaluate a MSA allocation completed by another provider to ensure accuracy and that the lowest defensible allocation has been obtained. Indiana (IN) Screening Tools - the tools below are provided as a resource to aid in the screening of alcohol and drug use. This service is dependent on cooperation from prior TPRA or TPA to accurately provide historical data related to prior CMS reporting submissions. Appeals or Grievances: If you or someone you are helping has questions about the grievance or appeal process, please call: 1-866-436-0457 or complete the MTM “contact us” on-line form. Delaware (DE) NURSE PROGRESS MONITORING-TELEPHONIC CASE MANAGEMENT. Negotiating from a position of strength, Optum provides unparalleled access to data combined with well qualified clinical expertise in MSP compliance. Your Link Password Owner or ID Administrator that you select during registration will need to complete your request in Link Security. Colorado (CO) All outpatient and EAP claims should be submitted electronically via Provider Express or EDI. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011, Wellness Assessment Forms * does not apply to Unison membership. Referrals   |   Arkansas (AR) Adult Wellness Assessment (English): blank or editable, Youth Wellness Assessment (English): blank or editable, Adult Wellness Assessment (Spanish): blank or editable, Youth Wellness Assessment (Spanish): blank or editable. Our Settlement Solutions have been called best-in-class and for good reason. Transcranial Magnetic Stimulation (TMS) Authorizations Forms, Washington (state) IMC Critical Incident Report Form, Disclosure Provider Form – Roster Template (Excel file), Disclosure Provider Form – Roster Addendum, MN Care Advocate’s Fax # is 1/855-454-8155, MN Autism and EIDBI Forms and Information, Mental Health Intensive Outpatient Program Forms, Assertive Community Treatment (ACT) Form (for non-contracted providers only), DBT Request Form (for non-contracted providers only), Intensive Community Based Services (ICBS) Form, Intensive Community Based Services (ICBS) Monthly Update Form, Medica Behavioral Health Services and Authorization Requirements, Mental Health Retrospective Request Form - Medica Behavioral Health - MN CAC, Transcranial Magnetic Stimulation (TMS) Initial Request Form, Note: Adobe Acrobat Reader is required to view and print PDFs, Clinician Tax ID - Add / Update Online Form, Clinician Expertise/Specialty Attestation, Electronic Payments & Statements (EPS) here, http://bookstore.gpo.gov/catalog/government-forms-phone-directories, Optum Idaho Optum Supports & Services Manager (OSSM), Blank Person-Centered Service Plan Form in English, Blank Person-Centered Service Plan Form in Spanish, APA DSM5 Level 2 Substance Use Parent of Child Age 6 to 17, Telephonic Support Services - Provider Handout, MBH Telephonic Support Services - Referral Information for Providers, Telephonic Support Services - What Members Can Expect, Medication Assisted Treatment (non-methadone) Request Cover Sheet, Methadone Maintenance Assessment Cover Sheet, Substance Abuse Retrospective Request Form, Substance Abuse Service Request Cover Sheet. Michigan (MI) CONDITIONAL PAYMENT APPEAL SERVICES TIER 2. Choose Optum. Nebraska (NE) Louisiana (LA) If you wish to appeal a denied or reduced claim, there are some specific steps to take. Connecticut (CT) Claims that need to be filed on paper should be done on the red 02/12 1500 Claim Form. If provided authorization, Optum will manage all incoming Conditional Payment correspondence on behalf of the RRE. OptumRx Prior Authorization Guidelines. Targeted follow-up with the treating physician is recommended for all Medication Analysis and CCCR referrals following peer outreach. Wellness Assessments are available here, on the Forms page, at the secured user section, or by mail. Missouri (MO), Montana (MT) Submit the original bills with the claim form and be sure to keep copies for your records. are available to discuss MSP/MIR Mississippi (MS) Ohio (OH) 108 - OPOH - Appendix K - A.K.4 - Formal Appeal Response Form (pdf) 2016-07-13 109 - 01 - OPOH - Appendix L - A.L.1 - Monitoring Psychtropic Medications (pdf) For more information, please contact expectmore@optum.com. South Carolina (SC) Written verification of Conditional Payment is obtained and provided to the adjuster. Upon identification of items in a MSA lacking proper clarity, including outdated recommendations or drug therapies where the prescribed reason for usage is unclear, a clinical nurse or physician will then outreach to the treating physician(s) to discuss the concern(s) and obtain verbal and written clarification of the current and/or future treatment recommendations. Log In | First-time User | Global | Site Map. After Optum has established the claim with the BCRC, the claim will be monitored based on an agreed upon schedule to ensure Conditional Payment demands are identified and responded to in a timely fashion. For faster claims reminbursement with less hassle, it is strongly encouraged that you sign up for electronic funds transfer (EFT) via our Electronic Payments & Statements (EPS) here. If the CMS approval comes back at a countered higher amount to the initial recommended MSA, a resubmission for reconsideration may be possible. Optum’s Medication Analysis provides a comprehensive assessment of the injured party’s pharmacy records and current medication regimen by an Optum clinical pharmacist, trained in CMS guidelines. Optum will provide a consult with one of our staff attorneys for assistance with settlement language, settlement strategy discussion and review of current law. Portal. For the confidentiality of those clinicians whose Tax ID is their social security number, all clinician numbers presented on these WA forms are Optum-assigned numbers. Optum has led the way by sharing our experience and knowledge with our clients with every MSA completed. Optum will then contact the claim handler and provide the appropriate recommendation. We help you navigate the CMS dispute and appeals process by reviewing disputable charges and providing recommendations for resolution and reduction. AUTOMATED NOTIFICATION/VERIFICATION SERVICE. You don’t have to choose between compliance and cost savings. Oregon (OR) Optum applies our consultative approach that brings pharmacy, medical claims and legal expertise together to review appropriateness of care and mitigation opportunities. Note: *Includes up to two hours of Peer-to-Peer review/interaction. Oklahoma (OK) New York (NY) DEPARTMENT OF TREASUREY OFFSET RESOLUTION. Optum Pharmacy Confidential Information Release Form *Confidential Information Release Forms alone do not grant authorization to your representative to file appeals on your behalf. SUBSCRIBE TO BLOGS. Hawaii (HI) Optum will receive, scan, log and forward the notice to the appropriate party for handling. Outreach is recommended on all Medication Analysis and CCCR assignments when mitigation opportunities are identified. Guides It starts with the Part D detector, which identifies opportunities for pharmacy costs to be mitigated for Medicare Set-Aside (MSA) purposes. See lower right of this page for a link to additional information. The Wellness Assessments here can be printed blank or, with the editable form, you can type in the information for the top section before printing the form. Optum will contract the Department of Treasury and provide the appropriate documentation to secure the repayment of the principle and interest taken as an offset. District of Colombia (DC) US Virgin Islands (VI) If you have an Optum ID connected to a TIN but are still unable to access specific Link tools, please ask your Password Owner or ID Administrator to make changes to your account access in the Link Security Tool. Through Real Appeal, you get a transformation coach who leads weekly online group sessions, online tools to help you track your food, activity, and weight loss progress, and a success kit with recipes, scales workout DVDs, and more! Nevada (NV) Iowa (IA) As part of the review and preparation of the allocation the following items are considered: A quality MSA ensures your interests are protected while containing costs. Once Optum has completed the allocation and received a request from the client for CMS approval, Optum will prepare the necessary documentation and proceed with CMS submission. Optum will review another vendor’s MSA for accuracy, update the allocation, if required, and submit to CMS for approval. Virginia (VA) Our clinical pharmacists and nurses review treatment plans to provide actionable plans to reduce MSA exposure. If the client is a Pharmacy Benefit Management (PBM) client of Optum, a list of claims will be provided to the client that meets these criteria. Arizona (AZ) Wyoming (WY). Optum’s dedicated CMS submission team will review the previously approved MSA and additional information provided to determine if the claim qualifies for an Amended Review and will then revise the MSA allocation and submit the Amended Review with the necessary supporting documentation to CMS for approval.