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Features and benefits

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Comprehensive, services-based solution

Optum® Claims Administration includes intake, processing and servicing of all claim types for a state’s Medicaid population. Portals are available for members, providers and state agency staff. Services are fully supported by contact centers, including telephone, mail and interactive voice response.

 

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  • The Optum Claims Administration module consists of multiple components constructed primarily from pre-built commercial-off-the-shelf (COTS) products. The Optum Integration Layer, or OIL, is the technology that enables our modular solutions to be interoperable with each other, with many third-party vendors’ systems, and with state systems. It also enables modules and components to be easily switched as a state’s needs change. The nine components of Claims Administration include intake, EDI claims editing, program integrity, benefit administration, claims pricing and adjudication, self-service user portals, contact centers and correspondence, appeals and grievances, and document management.

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Seamless implementation

Our prebuilt claims module uses flexible, commercial off-the-shelf (COTS) technology that can be configured to meet your state's Medicaid requirements. We can implement it faster than traditional custom builds, completed in about 15–18 months. 

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Improved provider satisfaction

Providers receive immediate feedback and education on claims submitted through the provider real-time adjudication portal. That means fewer denials and less rework. Providers are able to update and readjudicate their claims to ensure accurate results and timely payments.

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Accuracy you can depend on

We process more than 2.8 billion claims per year with more than 99.5% accuracy. We apply our expertise to provide transparent claims processing, with efficient workflows and reporting. Our solution is evergreen. Optum maintains all baseline federal regulations, so you don't have to. 

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Modular and interoperable

The Optum Integration Layer — OIL — is the technology that enables our modular solutions to smoothly interoperate with each other. Claims Administration interoperates with existing systems or other vendors’ modules, giving states flexibility with their MMIS replacement.

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Additional benefits

ROBUST PROGRAM INTEGRITY: 
This includes solutions placed along the claim cycle to enhance pre-payment control over fraud, waste, abuse and errors.

SUPPORTS CMS REQUIREMENTS:
Our solution is MMIS-certifiable and fully supports MITA 3.0 and the Seven Standards and Conditions.

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Modern, secure, evergreen platform

Optum Claims Administration is one of many modular solutions on our Optum® Medicaid Management Services (OMMS) platform. Functions are prebuilt. And Optum is responsible for all system maintenance and software updates, while protecting your data and keeping it separate from other client data.

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