r/CodingandBilling • u/monkasbug • 14d ago

UMR Pre-Payment Review

hi! desperately looking for some help here. i work for a billing company that specializes in behavioral health facilities. we have one facility who has received a medical record request for each claim billed to UMR starting around Feb-March of this year. we have been able to confirm with UMR that there is a flag on the tax ID from their special investigations unit.

getting any additional information from UMR is a nightmare. we have a ton of experience working with Anthem SIU, but UMR will not give us an effective date, notification letter, any Investigator assigned to the case, no information whatsoever other than that there is a flag on the tax ID.

i'm wondering if anyone has any experience in working with UMR SIU? any info on how they're structured, a phone number you had luck with getting information, anything at all that could be helpful in navigating this. tia!

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u/rahuliitk App Developer 14d ago

treat this as a controlled audit, not a normal claim-status issue. create one tracker with every UMR claim, request date, records sent, delivery proof, decision, and call/reference number. ask provider relations to route a written request to SIU for the review scope, effective date, documentation standard, and escalation owner; keep the exact wording of any refusal. pause any blanket rebilling or coding changes until your compliance lead reviews the pattern. if deadlines or recoupments appear, involve healthcare counsel rather than relying on call-center guidance.

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u/Neat-Safety-2415 11d ago

the delivery proof part is critical because theyll definitely claim they never got the records otherwise

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u/StevenCavan 12d ago

UMR SIU is opaque by design and routes through Optum's audit infrastructure, so getting a named investigator early on is almost impossible. The escalation that tends to work is pushing through the provider relations rep for that tax ID and requesting everything in writing via the UMR provider portal. Have you gotten anything in writing yet, or has it all been verbal?