Optum Pre-Payment Hospital Bill Review

Starting December 31, Optum will support Premera Blue Cross Individual plans by reviewing certain inpatient facility claims as part of the claims process.

What to Know

• Diagnoses-Related Group (DRG) Audit: Confirms billing matches care and follows coding rules (ICD-10-CM, CMS DRG definitions). This helps prevent mistakes and supports correct payment.
  • Claims won’t be paid if the medical record doesn’t match the billed DRG. You’ll need to fix and resend. The healthcare provider gets a report with next steps if more information is needed.

• Itemized Bill Review (IBR) Audit: Checks hospital charges for errors (duplicate charges, non-billable items, or unrelated services) and follows UB-04 billing rules.
  • If there’s a problem, we’ll fix the claim and pay the right amount.