As you know, health plans conduct medical record review programs to ensure accurate billing, coding, and documentation practices and compliance with requirements. Point32Health engages Optum to assist in medical record review as part of our claims auditing program for some lines of business, and will begin to utilize Optum for the Tufts Health Plan products noted above, effective Nov. 1, 2025.
If your claims are selected as part of the medical record review process, you will receive a letter from Optum requesting medical records and billing documents related to specific claims. The purpose of the review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly and documented to support the services billed.
The medical record request letter offers guidance on what documentation is needed. Please keep in mind that a provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.
The request letter also provides detailed instructions on how to submit the requested documentation. Providers will have the option of submitting the necessary files by secure internet upload through the Optum portal, mail, or fax.
It’s important to submit the requested information in the timeframe noted to avoid the claim being denied due to lack of response. If the medical record review determines that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers may dispute the result of reviews, and instructions on submitting an appeal are included in the determination letter from Optum.
If you receive a medical records review request and have questions, please reach out to the Optum contact listed on the letter. We appreciate your cooperation with this program.