Premier Medical Appeals (PMA) clinical staff is skilled in developing evidence-based appeal letters, effectively establishing why a procedure or charge should be covered.
Premier Medical Appeals will generate a letter of medical necessity to obtain approval from the health insurance plans for services such as surgical procedures, high dollar prescriptions, and post-Acute Care admissions.
Premier Medical Appeals will work concurrently with the Inpatient Case Management team and utilize current Centers for Medicare and Medicaid (CMS) regulations, Milliman Care Guidelines and InterQual criteria to assess the appropriateness of the level of care.
Premier Medical Appeals will review medical records to ensure the medical services provided are accurately coded and billed.
Premier Medical Appeals will complete a detailed review of medical records to ensure the medical services provided are accurately coded. Premier Medical Appeals will complete the appeals processes following verification of correct billing codes.
Premier Medical Appeals contacts Payers for missing information or clarification necessary to initiate the appeals process, obtain authorization, and claims reprocessing. Premier Medical Appeals will continue to follow up with Payers to ensure proper payment has been received.
Premier Medical Appeals will provide comprehensive review of available medical records. In instances where admission orders are unsigned, documentation is inadequate, Milliman Care Guidelines, InterQual criteria or CMS regulations are not fulfilled, Premier Medical Appeals will make recommendations to provide education to the Case Management Department. Premier Medical Appeals will make recommendations to accept an alternate level of care wherever possible.
Premier Medical Appeals contacts payers for missing information or clarification necessary to initiate the appeals process, obtain authorization, and claims reprocessing. Premier Medical Appeals will continue to follow up with payers to ensure proper payment has been received.
Premier Medical Appeals generates monthly detailed reports, identifying all denials by types, payers and physicians. As a process quality metric, the report also tracks claim aging both from the facility and within PMA. All data can be uploaded into client systems upon request to ultimately support revenue cycle decision-making.
We also offer a comprehensive consulting service tailored to specific needs as Case Management workflow, Denial Management, Admissions Verification, Utilization Review, and Provider Education and Training.
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