Pre-Payment Claims Review
FULL URAC ACCREDITATION IN UTILIZATION MANAGEMENT
Accreditation by the URAC ensures that only appropriately trained, qualified clinical personnel conduct and oversee the utilization review process, that a reasonable and timely appeals process is in place, and that medical decisions are based on valid clinical criteria.
RENT TO PURCHASE EDITS
Our system allows us to limit monthly rental amounts up to a predetermined purchase price or period of rental months.
Appropriate use of quantity limits for a variety of medical supplies and services.
SERVICES THE PATIENT NEEDS
Our in-house staff of certified prosthetists and orthotists, respiratory therapists and nurses has developed medical criteria for each of the 1,800 - 2,000 HCPCS codes we manage. We also offer our expertise on claims submitted as exception or "not otherwise classified." Through a review of the member's diagnosis, a certificate of medical necessity, and the actual services provided, we determine a fair reimbursement arrangement.
DUPLICATE SERVICE DATE EDITS
Our system has sophisticated edits that prevent a single provider or multiple providers from furnishing medical items beyond what can be safely used by a member during a specified period of time.
ELIMINATION OF PROVIDER OVERLAP
Our system is able to identify the primary and appropriate provider of services and prevent other providers from fragmenting the billing or attempting to provide services previously furnished.
REDUCTION OF NOT OTHERWISE CLASSIFIED (NOC) SERVICES
Because we have experience in furnishing all the items we review, we can assist providers in identifying the appropriate procedure codes to utilize in submitting a claim for payment. This enables the health plan to better understand how their benefit dollars are being spent and identify additional savings opportunities.
UTILIZATION ANALYSIS REPORTING
We offer a variety of paid claims reports by diagnosis code, product and procedure code. In addition, we can integrate our data directly with the overall utilization of the insurer or employer/trust fund.
Third Party Administration