Claims Editing System iCES for Facility Claims

Catch Coding Errors Before They Happen

See why more than 65 health plans use the Optum™ Claims Editing System to streamline claims processing workflows, reduce reimbursement errors and improve payment integrity.

Commercial and Medicare Facility Claims Editing

The Optum™ Claims Editing System automatically checks each claim for errors, omissions, and questionable coding relationships. It tests the data against an expansive database containing millions of government and industry rules, regulations, and policies governing health care claims. The system automatically detects coding errors related to:

  • Unbundling
  • Modifier appropriateness
  • Diagnoses
  • Duplicate claims
  • Medical necessity

Edit rationale disclosure

The Optum Claims Editing System for Facility Claims offers an expanded database containing millions of facility-based rules sourced from Medicare Outpatient Code Editor (OCE), Medicare Code Editor (MCE), National Correct Coding Initiative (NCCI) and Local and National Coverage Determination (LCD/ NCD) guidelines. In addition to rule sets for commercial populations, rule sets are also available to support various Medicare reimbursement methodologies such as Medicare Advantage. The Optum Claims Editing System makes system rule sources and disclosure statements available to users to improve communication with facilities and to minimize the impact of potential inquiries and appeals.

Rules creation manager
The Optum Claims Editing System features a unique Rules Creation Manager that allows health plans to customize the software’s editing logic to support user-defined rules and reimbursement policies for facility claims. Users can create auditing logic, create new code relationships, and turn rules and edits off and on as necessary. Date-sensitive auditing ensures that edits are appropriately based on the date the service was rendered. Users can also define rules sequence and the level of automation for denials, profiling, and claims requiring additional review.

Contact Optum for a demonstration of this powerful integrated claims editing functionality for facilities and the benefits that it can deliver for you.

  • Powerful claims editing platform for inpatient and outpatient facility claims
  • Unique Rules Creation Manager enables customization of the software’s editing logic to support user-defined rules and contractual reimbursement policies and methodologies
  • Integrates with published CMS regulations and guidelines to provide transparency into edit rationale
  • Customize the application by facility, employer and payment methodology
  • Catch potential overpayments before an APC or DRG is assigned and payment is rendered