Third party administration

Our bill review services help maximize savings for clients and ensure injured employees receive quality care that is appropriate for their injury. Our team includes dedicated nurses and bill reviewers who thoroughly examine notes and records to ensure that the treatments and charges are related to, and appropriate for, the diagnosis, injury, illness and/or program coverage.

Our services include:

• Fully integrated, real-time claims editing and service platform that supports industry best practices related to auto adjudication, fee schedule administration, benefit administration, eligibility management, authorization/referrals management, NCCI edits, case management, provider network management, and reporting and analytics
• Full-service mailroom with dedicated document management specialists who manage all inbound and outbound mail
• Document scanning solution and supporting technology that tracks each claim from the time it is received in the mailroom to final clean claim payment resolution
• Online self-service tools that allow members and providers to verify benefit eligibility and entitlement, access and view claims data, initiate communications and generate reports
• 24/7 contact center

Our clinical team provides valuable utilization review services including:

• Authorization reviews for medical necessity, severity and intensity of services
• Prior, retrospective and concurrent authorizations for certified conditions
• Assistance with referrals for medical needs such as inpatient hospitalization, rehabilitation, skilled nursing and post-acute care services, and home health care
• Discharge planning and post-discharge outreach in coordination with our case management team
• Pharmacy utilization reviews and physician advisor services to ensure consistent, proactive validation of appropriate medications

Our national provider networks can be customized based on program requirements and include fully credentialed providers in all disciplines and specialties.
Advantages include:

• Access to approximately 900,000 medical and ancillary service providers delivering quality care across the U.S and all U.S. territories
• A credentialing process and criteria that ensures hospitals, facilities, physicians and ancillary providers adhere to the appropriate industry standards; the process includes primary source verification of required licenses, certifications, insurance and care delivery credentials based on medical services provided
• Provider training, compliance and competence

Our proprietary, cloud-based technology includes an integrated platform that supports the entire claim continuum – from adjudication and bill processing to member services, network management, and reporting and analytics.

Key features include:

• Secure patient/member and provider portals offer 24/7 access
• Robust data analytics and actionable reports support continuous quality improvement
• Compliant with the Federal Information Security Management Act of 2002, National Institute of Standards and Technology, FedRAMP, and Office of Management and Budget federal standards and controls