Introduction to the Application of Optum
2018年10月31日 15:48
Code & Claims
1. Optum™ Claims Manager Professional
Optum™ Claims Manager Professional is a proven system that leverages advanced clinical
editing and reviews claims prior to submission to third party payers to improve reimbursement
rates, support provider compliance, and reduce operating expenses. This clinical editing
solution helps physicians identify inappropriately coded charges prior to claim submission.
https://www.optum.com/content/dam/optum3/optum/en/resources/fact-
sheets/ClaimsManagerProfessionalIntegration_Epic.pdf
2. Claims Edit System for professional claims
The Optum™ Claims Edit System® provides an extensive set of core rules that utilize historical
data to maximize your auditing capabilities for commercial, Medicaid and Medicare claims.
https://www.optum.com/content/dam/optum3/optum/en/resources/white-
papers/CES_Professional_Claims.pdf
3. Denial Management: Field-tested techniques that get claims paid
When adjudicated claims are returned unpaid, the insurer will indicate the reason on the
accompanying explanation of payment. These indicators, known as claims adjustment reason
codes (CARC), are applied at the line item — CPT® code — level.
https://www.optum.com/content/dam/optum3/optum/en/resources/white-papers/2806_Denial%
20Management_White%20paper_r3.pdf
4. Claims Edit System for Facility Claims
The Claims Edit System for Facility Claims offers an expanded database containing millions of
facility-based rules sourced from Medicare Outpatient Code Editor (OCE), Medicare Code Editor
(MCE), National Correct Coding Initiative (NCCI) and LCD/NCD guidelines. Rule sets are also
available to support various Medicare reimbursement methodologies such as Medicare
Advantage.
https://www.optum.com/content/dam/optum3/optum/en/resources/brochures/CES_Facility_Claims_Product_
Sheet.pdf
5. Optum™ Healthia Exchange
https://www.optum.com/content/dam/optum3/optum/en/resources/fact-
sheets/Optum_Healthia_Exchange_ps_10_2012.pdf
6. Claims groupings can improve research
Episode Treatment Group (ETG) recognizes comorbidities, complications and treatments that
significantly change a patient’s clinical profile, health care utilization and likely future costs.
Unlike other groupers, the Symmetry engine uses pharmaceutical prescription history, as well
as procedures and diagnoses, to determine and rank a patient’s primary and secondary
conditions, both acute and chronic. Symmetry relies on standard national procedure and
diagnosis codes for processing, and Optum converts most DHCS local codes into national
standard codes so that Symmetry can understand them.
来自 <https://www.optum.com/resources/library/claims-groupings-improve-research1.html>
7. Symmetry® Episode Treatment Groups® Measuring health care with meaningful episodes of
care
https://www.optum.com/content/dam/optum3/optum/en/resources/white-
papers/Symmetry_ETG_White_Paper_Analytics_815.pdf
8. Annual IHE Connectathon Tests Validate OptumInsight Technologies’ Ability to Enable a More
Connected Health System
In addition, the company successfully demonstrated interoperability of its Optum Computer-
Assisted Coding solution via the HL7 CDA (Clinical Document Architecture) standard. This
solution, powered by Optum’s patented LifeCode® natural language processing (NLP)
technology, enriches CDA documents with standardized ICD-9 (International Classification of
Diseases, 9th Edition), CPT (Current Procedural Terminology) and HCPCS Level II (Healthcare
Common Procedure Codes, Level II) codes.
来自 <https://www.optum.com/about/news/annual-ihe-connectathon-tests-validate-optuminsight-technologies-ability-to-enable-a-
more-connected-health-system.html>
9. ICD-10 services for health plans
Our services provide comprehensive support of a plan’s effort to:
• Achieve a smooth and timely migration to the October 1, 2015 compliance date
• Realize necessary compliance requirements
• Reach optimal financial performance
• Attain higher degrees of member satisfaction and quality of care with more specific clinical
data
https://www.optum.com/content/dam/optum3/optum/en/resources/brochures/ICD-10%20services%20for%
20health%20plans.pdf
10. Health care subrogation: combining science and art to maximize results
https://www.optum.com/content/dam/optum3/optum/en/resources/white-papers/HealthCareSubrogation-
CombiningArtScienceotMaximize%20White%20Paper.pdf
11. Optum Intelligent EDI
Intelligent EDI integrates with existing claim submission workflow processes, practice
management and hospital information systems.
https://www.optum.com/content/dam/optum3/optum/en/resources/brochures/iedi-overview-brochure.pdf
12. Optum® Actuarial Toolbox Proven, sophisticated and market-leading actuarial models for
health plans and benefits consultants
The Optum Actuarial Toolbox is a comprehensive suite of tools that meets a diverse set of
needs and provides solutions to health actuaries that can support many product lines, market
segments and populations.
https://www.optum.com/content/dam/optum3/optum/en/resources/fact-sheets/WF382903
_PAYER_Actuarial_Toolbox_Bro_HR.pdf
13. Strengthening payment integrity: subrogation and injury coverage coordination
There are more than 20,000 injury and disease classification codes, or ICD-9 codes. As many as
3,700 of them suggest a connection to an accident. Health plans may pay those claims without
necessarily knowing whether they truly are responsible.
https://www.optum.com/content/dam/optum3/optum/en/resources/white-
papers/StrengtheningPaymentIntegrity-SubrogtaionInjuryCoverageWhitePaper.pdf
14. Intelligent EDI Next-Generation Revenue-Cycle Management Capabilities —All within the EDI
Data Stream
Intelligent EDI helps providers increase revenue by identifying missed billing opportunities.
Positive edit capabilities within the solution alert users when potential codes or modifiers are
missing from claim. This enables users to review and correct errors before submission to earn
full reimbursement for all the care that was delivered.
https://www.optum.com/content/dam/optum/Images/email/Executive_Lead_Nurture/WP_Intelligent_EDI.pdf
Clinical Application
1. Intelligent Coding Technology from Optum Helps Hospitals Accelerate Transition to New
ICD-10 System and Improve Clinical Documentation
Enterprise CAC includes a Coding and Reimbursement Module that combines CAC technology
with comprehensive Optum reference, encoding and reimbursement tools. This single
application eliminates data hand-offs between the applications that scan and render diagnosis
and procedure codes from clinical records and those that apply the codes to billing statements
and other documentation.
来自 <https://www.optum.com/about/news/intelligent-coding-technology-from-optum-helps-hospitals-accelerate-transition-to-new-
icd10-system-and-improve-clinical-docum.html>
