Optum Rx Pharmacy claims

We are seeing the majority of Optum Rx network pharmacies back online and processing claims. As pharmacy services are restored, Optum Rx Pharmacy Network Audit has taken the following actions to address the concerns of our network pharmacy providers:

• Impacted pharmacies will not be audited through early April 2024.
• Claims that were filled but could not be submitted online during the Change Healthcare outage will not be audited or reviewed.
  • Upon notification by Pharmacies of inadvertent audits of such claims, Optum Rx will remove the claims from audits and clear any findings for the claims from the audits if applicable.
  • Upon notification by Pharmacies of Prescription Validation Reviews of such claims, Optum Rx will remove the claims from the reviews and clear any findings for the claims from the reviews if applicable.
• For Centers for Medicare & Medicaid Services (CMS)-directed audits, if more time is needed to gather the required documents, please notify us and we will work on obtaining an extension.
• Requests for extensions from Pharmacies with open audits will be reviewed on a case-by-case basis.

If you have any questions, please reach out to our Provider Relations team via the intake form located on our website: https://professionals.optumrx.com/resources/forms/pharmacyproviderrelationsform.html.