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Payment Integrity Solutions

Fecha: 31/03/23

Thank you for your continued partnership with Ambetter from WellCare of New Jersey. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim auditing. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.

For claims received on or after May 1, 2023, providers my experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Editing Area


Lines of Business

High Dollar IV Hydration

Requesting medical records to determine if documentation supports services billed and that those services were in accordance with policies and regulations related to IV hydration therapy.



Custom Fitted or Custom Fabricated Prosthetics or Orthotics


Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider



We thank you for your commitment to the care and wellbeing of our members and to the communities we serve.  Should you have any questions or concerns about this notification, please contact us at Provider Services 1-844-606-1926. Policies are posted on our website at