Search Our Site

Guidelines
Saving clients time and money, provide piece of mind when dealing with intricate cases.

In Patient Scenarios:

  • All in-hospital lasered patients
  • All cases where total costs minus specific deductible are >$350,000
  • All in-network cases with projected/actual LOS>21 days
  • All out of network cases with >4 day length of stay, total costs >$75,000, or Per-diem costs >$5000.
  • All cases where patient has had >3 acute to sub-acute transfers in 3 month time period
  • All cases where change in medical care plan, i.e. escalating dosages of drugs, is not supported by laboratory or radiology evaluation
  • All cases where payer UR reviewer is unable to elicit plan of care from provider.
  • All cases where plan is unable to get a PPO or non-participating provider discount
  • Admission with projected/actual LOS >7 days: Neonatal Intensive Care
  • Admission with projected/actual LOS >10 days: Long Term Acute Care Facility
  • Admission with projected/actual LOS >21 days: Rehabilitation Facility
  • Admission: Greater than 3 admissions within the last 6 months
  • Total Claim >50% of  Stop-Loss deductible (includes inpatient/outpatient, DME, ancillary services)
  • Patient with high resource utilization
  • Disclosure/Illness Date of Onset Issues
  • PRN cases at client discretion

Retrospective Medical Review:

  • All the above scenarios, except for the 50% notification cases.
  • All cases lacking Case Management or Utilization Review Notes where case management or utilization review is indicated but not performed

Specific Clinical Scenarios:

  • Patients receiving IV gamma globulin for any condition other than ITP or hypogammaglobulinemia
  • Other experimental/investigational drug/procedure questions
  • Patient in LTAC and no evidence of vent weaning or daily physician intervention
  • Questions regarding dosage/duration of therapies
  • Questions regarding off-label usage for FDA Approved Drugs
Hospital Out of Network Claims: Hospital Out of Network claims > $50,000

Hospital In-Network Claims:

  • Greater than $50,000 for PPO discount < 10%
  • Greater than $100,000 for PPO discount 10-20%
  • Greater than $200,000 for PPO discount >20%

Inpatient Daily Bed Rate Charges:

  • ICU Bed Rate >$4,000/day
  • Med-Surgery Bed Rate >$2,500/day

Implantable Devices-Other Carve Outs: > 50% of total billed charges

Chemotherapy/Radiation Therapy Claims: All individual claims greater than $15,000

Surgery/Chiropractic claims: Unlisted or New CPT codes

Claims with extensive laboratory/pharmacy charges

Dialysis Claims:

  • Monthly Dialysis Charges > $10,000
  • Individual Dialysis Charges > $2,000
  • Erythropoietin Charges (EPO) > $1,000

All Inpatient Psychiatric Claims

All other claims at your discretion

Do you have everything required to assess the claim? Is there a UB92, Itemized Bill, and Operative Report? All the documents are key to assessing a claim for adjudication. Remember, every claim is unique and all factors must be considered before adjudication. There is no single best course of action on claims even for the same patient from the same hospital during the same admission.

Below is a list of potentially catastrophic diagnoses that could require Case Management and close review. Weekly/Monthly reports should be run to identify new patients meeting these criteria. Be sure to request assistance immediately once you are notified that a member has an illness, injury, or requires services listed below the table.

AIDS/ARC/HIV PSYCH CONDITION REQUIRING HOSPITALIZATION
LEUKEMIAS, CARCINOMAS, HEMOPHILIA BURNS-> 20% TBA OR 2ND-3RD DEGREE
ANEURYSMS CEREBRAL INJURY-ANY CAUSE VALVULAR DISEASE
COMA CAD/CHF
CEREBRAL HEMORRHAGE ESRD/DIALYSIS
GUILLAN-BARREALS SPINAL CORD INJURY
ALL TRANSPLANTS CRANIOTOMY
ACUTE/CHRONIC HEPATITIS/CIRRHOSIS/LIVER DISEASE MAJOR CHEST/ABDOMINAL PROCEDURES
CYSTIC FIBROSIS/COPD NEONATAL CONG. ABNORMALITIES
CVA BIRTH TRAUMA, PREMATURE BIRTH
ADULT CARDIAC ARREST, ADULT RESP. ARREST, VENT DEPENDENCY NEWBORN RESP ARREST, NEONATE/INFANT RESP, DISTRESS & ICU > 7 DAYS
CHRONIC LOW BACK PAIN HIGH RISK PREGNANCY, PRETERM LABOR
AMPUTATIONS BRONCHOPULMONARY