New Medicare Claims Platform Launches May 1

On February 1, we notified you of a change to the system we use to process Medicare claims. To ensure a smooth transition for all our providers, we have extended our implementation date from April 1, 2023, to May 1, 2023. Please see details below to learn more.

What this means for our providers: Effective May 1, 2023, Optima Health will process any Medicare claims through our new claims platform. The platform will utilize Optum Claims Edit System® (CES) to administer reimbursement policy and claim edit rules for professional and institutional claims. Please be aware that claims submitted prior to this date will be processed based on the current editing system and will not be affected by this transition.

CES uses the following sources for its edits:

  • National Correct Coding Initiative (NCCI) edits, including Medically Unlikely Edits (MUEs)
  • Federal Register (the Daily Journal of the US Government that contains agency rules, proposed rules and public notices)
  • Medicare publications
  • Local and National Coverage Determinations (LCDs/NCDs)
  • Outpatient Code Editor (OCE)
  • Medicare Code Editor (MCE)

What do you need to do?

Because many other carriers with whom you work already use Optum’s CES, we do not anticipate this transition will disrupt how you work with Optima Health. CES will replace our legacy edits and automatically review and catch errors, omissions, and questionable coding. The end result will be streamlined claims, reduced reimbursement errors, and improved payment integrity. 

The transition to this editing system will enable Optima Health to manage cost-effective healthcare and delivery and reimbursement by identifying potentially incorrect coding relationships on submitted claims.

The benefits to you as the healthcare provider are as follows:

  • equitable reimbursement
  • efficient reimbursement
  • accurate and consistent claims processing and reimbursement

Electronic Funds Transfer (EFT) and Electronic Remittance Advices (ERA)

All EFT and ERA will be issued through PaySpan. This change will require the provider to create an account, if you do not already have one. For providers that currently access PaySpan, updates will be required.

New PaySpan users—how to register 

Providers can contact or 1-877-331-7154, option 1, for help obtaining registration codes and assistance with navigating the website. Provider Services Specialists are available to assist Monday through Friday from 8 a.m. to 8 p.m. 

If a provider is not loaded in the new Optima Health claims platform, or receives feedback from PaySpan that they are a new user with no provider entry in the PaySpan system, the provider will need to submit a claim to Optima Health and receive a paper check. This check will include registration information for PaySpan.

For current PaySpan users

If providers already have an account, there will be a single registration code that is tied to the pay to entry. If there are multiple pay to entries in Optima Health's claims platforms, providers will have multiple registration codes. To obtain a code, providers can contact PaySpan and provide their TIN/NPI.

If there are any questions, please contact a PaySpan Provider Service Representative at 1-877-331-7154. Please view this video to learn more about PaySpan.

EDI 837 enrollment process 

As we move into a new claims platform, non-participating providers will be required to submit an EDI 837 form to submit claims electronically. You can find this form on the Optima Health website.

Changes to claim numbers and other interface changes

This change will also bring new provider experiences to the detail-level information you receive from the Optima Health claims platform. We will continue to provide more specific information and support regarding what you can expect from these changes as we get closer to go-live. Please stay tuned!