ClaimsManager Facility™ Overview

One of the most customizable rules engines in the industry

OptumInsight ClaimsManager Facility, a sophisticated, yet easy to use clinical editing solution, helps hospitals identify inappropriately coded outpatient and inpatient facility claims prior to submission. Catching and correcting errors before claims are sent to the payers helps reduce denial rates, shorten A/R cycles, and capture more revenue.

Why OptumInsight ClaimsManager Facility?

This rules-based, front-end clinical editing tool offers the most advanced knowledgebases in the industry, with more than 16 million (over one million commercial and 15 million Medicare) facility coding relationships, accompanied by robust database editing functionality, to help you:

• Flag potential revenue opportunities for services that were not billed
• Reduce costs of re-working rejected claims
• Create customized rule sets to match payer-specific guidelines
• Comply with Medicare and commercial regulations with a consistent, automated standard

Edits outpatient and inpatient claims

Outpatient Editing

• Medicare Outpatient Code Editor (OCE)
• Facility – National Correct Coding Initiative (NCCI)
• National and Local Coverage Determinations (NCD/LCD)
• NCD - Payment policies developed by CMS and apply nationally
• LCD - Payment policies developed by the contracted Medicare Carrier (Medicare Part B – outpatient and physician claims)

Inpatient Editing

• Medicare Code Editor (MCE)
• Custom rules or facility specific rules using Rules Creation Manager

OptumInsight ClaimsManager Facility continuous updates:

• Quarterly knowledgebase update / bi-monthly NCD/ LCD updates
• Yearly/ bi-yearly software new feature releases
• Medicare Physician Quality Reporting Initiative (PQRI) edits and rules
• Annual CPT® and ICD-9-CM revisions