Helpful Hints for Claim Submission

Exclusions May Apply to Optum Benefits

Please note that a patient's Optum benefit plan may list benefit exclusions or specific conditions or circumstances for which the Optum plan will not provide reimbursement. To see if any benefit exclusions apply to the Optum policy for a specific patient, please check Eligibility & Benefits Inquiry online or contact Optum through the number on the back of the member's ID card. You may call Optum to inquire about benefit exclusions anytime during your patient's course of treatment.

Diagnosis Codes

Optum requires all clinicians to submit an ICD-10-CM Mental Health / Substance Use Disorder primary diagnosis code and encourages you to list all secondary diagnoses as clinically appropriate. 

Coordination of Benefits

On an annual basis, members are required to provide information on all other insurance coverage they have. If a patient's claims are pended indicating "COB verification required from member", the member should contact Optum directly using the number on the back of their ID card to update their COB information.

Medication Management

Psychiatrists and prescribing nurses are no longer required to obtain prior authorization or complete Outpatient Treatment Progress Reports (OTPRs) for their patients. The table below reflects some of the most frequently used CPT codes among prescribing clinicians that do not require prior authorization of benefits:

• 90791
• 90792
• E/M Code + 90833
• 90834
• E/M Code + 90836
• 99211
• 99251
• 99252
• 99253
• 99254
• 99255

How to Get Paid Faster

We want to pay you quickly for the services you provide to members. You can help by following these simple guidelines when completing and submitting a claim:

• Use CPT/HCPCS codes or service type/room type codes for all provider services
• Your primary diagnostic code must be an ICD code derived from DSM criteria. 
• Please be sure to enter the full diagnosis code. 
• For inpatient, residential and partial hospitalization programs the number of days should be broken out by the level of service
• Include the member's name, address, date of birth and member identification number
• Include assignment of benefits, if appropriate
• Indicate the place of service according to the codes below and the proper procedure code

Place of Service Codes for Professional Services

It is important for your professional fees to be submitted with the place of service code that matches the level of care provided.

Observation Bed

An outpatient place of service code should be used whenever the observation bed level of care lasts less than 24 hours and results in a discharge to a less restrictive level of care.

Claims Submission Address

For paper claims, only CMS-1500 forms and UB-04's (including itemizations) should be sent to the appropriate claims address.

Care Advocate Address

Appeals should be sent to the Care Advocate Center that issued the Adverse Benefit Determination.

Network Management Address

Changes to your demographic information (i.e., federal tax ID, address, phone number, etc.), can be requested on Provider Express through My Practice Info. Demographic change requests may also be faxed or mailed to your Network Manager. Fax numbers and mailing addresses for Network Management can be found on the Contact Us page under Network Management Contact Information.

Claims Customer Service Telephone Number

If you have any questions or concerns regarding your Provider Remittance Advice, please call the number on the back of the member's ID card.

National Provider Identifier (NPI)

The CMS-1500 Health Insurance Claim Form has two distinct fields for placement of an NPI number. The first is field 24J and includes all of the unshaded rows under “Rendering Provider ID #.” For each line of billed service, the rendering provider NPI number should be listed. The second field is 33a. This field appears under field 33 and is reserved for the “Billing Provider.” In most cases the “Rendering” and “Billing” provider is the same. Nonetheless, the NPI should be entered in both places on the claim form. The inclusion of the NPI in both fields is essential to timely and accurate processing of claims.

For more information, please refer to the National Uniform Claim Committee (NUCC) 1500 Health Insurance Claim Form Reference Instruction Manual. From the NUCC homepage, click “1500 Claim Form” in the menu bar at the top of the page.