Claims Editing Knowledge Base Overview

The OptumInsight Claims Editing KnowledgeBase provides rich data to help health plans identify costly coding inaccuracies. Since 1991, the OptumInsight Claims Editing KnowledgeBase has provided a foundation for consistent and clinically-sourced claims review and seamless integration with claims adjudication systems to improve the efficiency and accuracy of claims processing.

Identify Inappropriate Coding Relationships Before Reimbursement

The OptumInsight Claims Editing KnowledgeBase detects more than three million improper coding relationships relating to CPT^® and HCPCS Level II procedure codes and ICD-9 diagnosis codes including:

• Unbundling
• Incidental Services
• Mutually Exclusive Services
• New Patient Visit Auditing
• Diagnosis to Procedure Appropriateness
• Surgical Assistant Appropriateness
• Maximum Frequency Per-Day Editing
• Place of Service Editing
• Procedure/Diagnosis/Modifier Validations
• Multiple Procedure Reductions

Complete Commercial and Medicare Edit Sourcing and Disclosure

OptumInsight Claims Editing KnowledgeBase modules are designed to support commercial or Medicare claims editing. The modules may be implemented as an integrated solution or as separate edit tables. Both modules are updated quarterly to reflect the most current industry coding guidelines.

The Medicare module draws upon coding guidelines established by the National Correct Coding Initiative (NCCI) and the National Physician Fee Schedule Database (MPFSDB) to audit claims based on Medicare guidelines.

The commercial module enables claims processors to rapidly understand and explain the rationale behind edits on commercial claims. The module identifies specific CPT^® codes, Centers for Medicare and Medicaid Services (CMS), and medical specialty society guidelines, and provides complete details on assumptions used to develop edit tables for CPT® code evaluation and management, anesthesia, surgery, radiology, pathology, laboratory, and medicine codes, as well as HCPCS Level II.

Easy Integration with Claims Adjudication Systems

The OptumInsight Claims Editing KnowledgeBase is a flexible, table-driven knowledgebase that requires no unique hardware and easily integrates with many claims adjudication systems. More than 175 clients have implemented this rich, clinically supported coding data source to complement existing claims editing and adjudication systems.

Contact OptumInsight for a demonstration of this solution and the benefits that it can deliver for you.

CPT^® is a registered trademark of the American Medical Association.