Medical Necessity

Review claim to ensure documentation compliance with clinical, industry and policy standards

Cross reference Physician records and provider records to ensure corroboration of care.

Confirm requested services, components and technology are aligned with medically necessary care

Verify that coding is complaint with appropriate industry, government and policy compliance standards

Verify and validate the application of '99' codes for unlisted procedures

Audit claim to identify duplicate codes

 Exam claim to confirm codes for services and products have not been unbundled

Validate pricing to industry "Usual & Customary" (U&C) pricing profile.

Cross referenced pricing and coding to Manufacturer Suggested Retail Price (MSRP)

For '99' unlisted codes, corroborate and substantiate a fair provider profit markup based upon acquisition cost and clinical labor to provide care.

eXperienced

eXpert

eXcellence