HIPAA

In anticipating the affect of the evolving regulatory climate on our clients, Total Claims Review has designed and developed a program for your "complaint and appeals" related needs.

HIPAA regulations stipulate that "All consumers have the right to a fair and efficient process for resolving differences with their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review." To that end, Total Claims Review offers a two-tier program which will both enhance and support your existing internal review procedures, as well as provide the administration of the external review process of disputes for which we did not participate in the preliminary claims decision or internal review. Our knowledge and proven record serving the needs of ERISA regulated health plans will provide you with the added expertise and customized support that you need to comply with the HIPAA appeal regulations.

Internal Review Requirement: When you are presented with a dispute by a plan participant regarding a prior claims decision in which Total Claims Review was involved, Total Claims Review will re-consider the situation and render a timely and thorough objective review determination by qualified professionals who did NOT participate in the original claims decision. In the event that Total Claims Review did not participate in the original decision, we will conduct a thorough review of the claim and all corresponding documentation. Additional medical records as well as an opinion by a qualified physician peer may be requested included as deemed necessary by our review team.

External Review Requirement: In such cases when Total Claims Review was NOT involved in the initial claims determination, we will administer an objective re-consideration review conducted by our experienced professional nurse review team and our panel of Board Certified Physician specialists. The ultimate determination will be rendered and documented by a same-specialty peer physician of the physician who provided the service to the participant.

Our External Review program is available both to health plans whom do not regularly or currently utilize our Case Management and Review services, as well as to our current clients for claims in which we did not participate in the initial and/or re-consideration internal review process.

The process will be expedited to satisfy the HIPAA time limit guidelines for completion of the process and will be performed in accordance with both ERISA and HIPAA regulations.