New Medicare Claims Platform - An Update

Additional information to help you prepare for upcoming changes.

As previously announced, on May 1, 2023, Optima Health will process any Medicare claims through our new claims platform, QNXT. To help you prepare for changes, we are sharing several updates. Please review the information below and share with your colleagues.

Overview of Changes

Existing Process Process Through New Platform – Medicare ONLY
Provider Remits

Provider Connections Portal

Accessible via Payspan

PaySpan Access and Support

Provider Connections Portal

Providers can contact or 1-877-331-7154, option 1, for help obtaining registration codes and assistance with navigating the website

Pay-To Entity

Previous process allowed providers to use DBA; pay-to entity did not have to match the provider’s name

Requires that the legal business name of an entity be listed as the pay-to

Accessing Claims and Authorizations

All Medicare claims with dates prior to May 1, Medicaid, and commercial claims can still be found using the original provider ID number.

When researching Medicare claims or authorizations with dates of service on or after May 1, select the provider ID that beings with the letter “P” from the drop-down menu.

Changes to PaySpan for Medicare Remits

As an additional reminder, all Medicare support processes for PaySpan (password resets, etc.) will be managed through PaySpan. Remits and processes for other Optima Health Medicaid and commercial products will not change.

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 am to 8 pm.

If a provider is not loaded in our new claims platform, or receives feedback from PaySpan that they are a new user with no provider entry in 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 payto entry. If there are multiple pay to entries in Optima Health's claims platforms, providers will have multiple registration codes. To obtain code, providers can contact PaySpan and provide 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.

Changes In Experience for Remit Pay-To Entity

Our new claims platform for Medicare claims requires that the legal business name of an entity be listed as the pay-to, demonstrating on remits and payments to providers. This may create a change in experience if your group has traditionally been paid under a DBA or alternative group name.

Billing Guidelines Reminder and Potential Changes to Claims Processing Experience

As we migrate to the new claim platform, some configuration and processing requirements may differ from your past experiences with Optima Health as we continue to align to industry standard processing and claims adjudication.

Please continue to follow standard billing guidelines for Medicare claims submission, and be aware that some providers may experience denials for incorrectly submitted claims. To be a proactive business partner through this process, Optima Health is also monitoring claim activity network-wide during this transition to identify any potential trends that could create negative experiences in claims payment.

We will reach out directly to support groups in this case, and we are always available to answer questions via Provider Relations:

  • 1-800-229-8822 for LTSS or medical providers
  • 1-800-648-8420 for behavioral health

Details About The New System

The platform will utilize 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

If you have any questions regarding this notice, please contact your assigned Network Educator at 1-877-865-9075, option 2.