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Optum is an approved NASPO ValuePoint supplier partner of the MMIS Claims Processing and Management Module to state Medicaid agencies nationwide. Optum Claims Administration Services is a COTS-based, MITA-aligned module delivered as a service (Business Process as a Service, BPaaS).

Core offering: Claims Administration ​Services Module

  • Adjudicate, edit, price and determine reimbursement amounts for health care claims
  • Process service authorizations, third-party insurance liability, and calculate member liabilities
  • Includes a robust financial management capability for back-end financial functionality of paying claims, data tracking and reporting

Option B: Member and provider call center

Optum Call Center services is a HIPPA-compliant contact center for members and providers. They answer a broad variety of call types and questions on policies and claims for state Medicaid programs. Using automated call distribution and workforce management technologies, our solution includes multiple HIPPA-compliant communication methods along with performance management call-monitoring and more.

Option C: Federal Reporting 

Our Federal Reporting Solution has three components:

  • Optum Management and Administrative Reporting System (MARS) is a financial reporting and analytical solution. It provides CMS Program Management certification and advanced capabilities to support the management and oversite of Medicaid programs.
  • Optum Fraud and Abuse Detection System (FADS) meets the Program Integrity checklist items from the Medicaid Enterprise Certification Toolkit (MECT).  
  • Operational reporting capabilities within the Optum Claims Administration Services module covers claims administration, utilization management and financial management requirements. 

Learn how we can partner with your state agency.