Medical Claim Review

In coordination with our Utilization Management and Case Management programs, we also provide Medical Claim Review – which focuses on claims that hit certain criteria or edits placed within our Claim system. This checkpoint works toward our common goal of containing health care costs while ensuring quality medical care for plan members.

Providing a Checkpoint
for Balancing Cost and Quality

Our Medical Claim Review area consists of registered, in-house nurses and physicians who perform in-depth review of services to determine appropriateness of care. Our program evaluates:

• Charges for undocumented services or procedures
• Excessive charges for provider services and supplies
• Evaluation for medical necessity of services and supplies
• Billing or data entry errors
• Claims exceeding usual and customary guidelines
• Benefit verification and limitation
• CPT and DRG coding accuracy

Focused Claim Review –
Outpatient High End Radiology

We offer an intense, focused claim review for outpatient high end radiology procedures. This review is designed to manage the escalating costs of these frequently over utilized outpatient diagnostic procedures:

• PET – Positron Emission Tomography
• SPECT – Single Photon Emission Computed Tomography
• MRI – Magnetic Resonance Imaging
• MRA – Magnetic Resonance Angiography
• CT – Computerized Tomography

We review select cases for medical necessity after services are rendered but prior to claims payments. Members may request a predetermination of benefit.