Claims Editing System (iCES) for Facility Claims Overview

Commercial and Medicare Facility Claims Editing

The OptumInsight Claims Editing System automatically checks each claim for errors, omissions, and questionable coding relationships by testing the data against an expansive database containing millions of government and industry rules, regulations, and policies governing health care claims. The system automatically detects coding errors related to unbundling, modifier appropriateness, diagnoses, and duplicate claims. Medical necessity edits are also provided to help payers detect procedures billed without supporting diagnoses or not medically necessary based on National and Local Coverage Determinations.

Edit Rationale Disclosure

The OptumInsight Claims Editing 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 Local and National Coverage Determination (LCD/ NCD) guidelines. In addition to rule sets for commercial populations, rule sets are also available to support various Medicare reimbursement methodologies such as Medicare Advantage. The OptumInsight Claims Editing System makes system rule sources and disclosure statements available to users to improve communication with facilities and to minimize the impact of potential inquiries and appeals.

Rules Creation Manager

The OptumInsight Claims Editing System features a unique Rules Creation Manager that allows health plans to customize the software’s editing logic to support userdefined rules and reimbursement policies for facility claims. Users can create auditing logic, create new code relationships, and turn rules and edits off and on. as necessary. All edits are applied using date-sensitive auditing to ensure that appropriate edits are applied based on the date the service was rendered. Users can also define the sequence in which rules are applied and can define the level of automation for denials, profiling, and claims requiring additional review.

More than 65 health plans use the OptumInsight Claims Editing System to streamline claims processing workflows, reduce reimbursement errors and improve payment integrity. Contact OptumInsight for a demonstration of this new powerful integrated claims editing functionality for facilities and the benefits that it can deliver for you.