Exclusions May Apply to Optum Benefits
Please note that a patient's Optum benefit plan may list benefit exclusions or specific conditions or circumstances for which the Optum plan will not provide reimbursement. To see if any benefit exclusions apply to the Optum policy for a specific patient, please check Eligibility & Benefits Inquiry online or contact Optum through the number on the back of the member's ID card. You may call Optum to inquire about benefit exclusions anytime during your patient's course of treatment.
Optum requires all clinicians to submit an ICD-10-CM Mental Health / Substance Abuse primary diagnosis code and encourages you to list all secondary diagnoses as clinically appropriate.
Coordination of Benefits
On an annual basis, members are required to provide information on all other insurance coverage they have. If a patient's claims are pended indicating "COB verification required from member", they should contact Optum directly to update their coverage information.
Psychiatrists and prescribing nurses are no longer required to obtain prior authorization or complete Outpatient Treatment Progress Reports (OTPRs) for their patients. The table below reflects some of the most frequently used CPT codes among prescribing clinicians that do not require prior authorization of benefits:
- E/M Code + 90833
- E/M Code + 90836
Open Authorization for Routine Outpatient Psychotherapy
Members will continue to contact Optum to obtain referrals and obtain an open certification. This open authorization allows the member to receive treatment from any network clinician. It is valid for a maximum of 12 months, up to the member's benefit limit.
To inquire about authorization of non-routine outpatient services (such as psychological testing or EAP services), please call the number on the back of the member's insurance card.
How to Get Paid Faster
We want to pay you quickly for the services you provide to members. You can help by following these simple guidelines when completing a universal claim form or submitting a bill:
- Use CPT/HCPCS codes or service type/room type codes for all provider services
- Your primary diagnostic code must be an ICD code derived from DSM criteria. The DSM-5 includes ICD codes along with the DSM diagnostic criteria and descriptor or label. Note that the DSM-5 includes both ICD-9 and ICD-10 codes. Until the industry-wide change to ICD-10 occurs (currently expected to be October 1, 2015), you should continue to use only ICD-9 codes for billing.
- Please note that Optum will not accept code 799.9 or diagnosis deferred
- For inpatient, residential and partial hospitalization programs the number of days should be broken out by the level of service
- Include the member's name, address, date of birth and member identification number
- Include assignment of benefits, if appropriate
- Indicate the place of service according to the codes below and the proper procedure code
Place of Service Codes for Professional Services
It is important for your professional fees to be submitted with the place of service code that matches the level of care provided.
|Level of Care||Place of Service|
|Observation Bed Consult||22 or 52|
|Inpatient Hospital Consult||21|
|Inpatient Psych Facility Consult||51|
|Emergency Room Consult||23|
|Partial Hospital||22 or 52 (psychiatric facility)|
|Intensive Outpatient Program
|Residential||21 or 51|
|Outpatient - Office Location
An outpatient place of service code should be used whenever the observation bed level of care lasts less than 24 hours and results in a discharge to a less restrictive level of care.
Claims Submission Address
For paper claims, only CMS-1500 forms and UB-04's (including itemizations) should be sent to the appropriate claims address.
Care Advocate Address
Appeals should be sent to the Care Advocate Center that issued the Adverse Benefit Determination.
Network Management Address
Changes to your demographic information (i.e., federal tax ID, address, phone number, etc.), can be requested on Provider Express through My Practice Info. Demographic change requests may also be faxed or mailed to your Network Manager. Fax numbers and mailing addresses for Network Management can be found on the Contact Us page under Network Management Contact Information.
Claims Customer Service Telephone Number
If you have any questions or concerns regarding your Provider Remittance Advice, please call the number on the back of the member's ID card.
National Provider Identifier (NPI)
The CMS-1500 Health Insurance Claim Form has two distinct fields for placement of an NPI number. The first is field 24J and includes all of the unshaded rows under “Rendering Provider ID #.” For each line of billed service, the rendering provider NPI number should be listed. The second field is 33a. This field appears under field 33 and is reserved for the “Billing Provider.” In most cases the “Rendering” and “Billing” provider is the same. Nonetheless, the NPI should be entered in both places on the claim form. The inclusion of the NPI in both fields is essential to timely and accurate processing of claims.