PROGRAM COMPONENTS

For the purposes of description, the following outlines the various components available. However, it has been our experience that our integrated and global approach to Utilization Management eliminates fragmenting and duplication of our services. Our staff are specifically trained and experienced in all elements of the program, and therefore the components are not regarded as separate entities.

AVAILABLE ELEMENTS OF THE PROGRAM

Determination of Eligible Services: The determination of covered or non-covered services by reference to the Plan Document and/or the Plan Administrator.

HIPAA Compliancy - Internal and External Appeal Program: 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.

Pre-Admission Certification or Notification: A Plan requirement which necessitates a participant, dependent, provider, or any other person designated by the participant to call the toll free number in advance to report the location, scheduled time, and provider of the proposed hospital confinement or other specified care, or the occurrence of emergency care. Pre-Certification programs will serve to certify days and both programs will act as a triggering strategy for identification of situations which will be positively impacted by additional Program components.

Pre-Admission Review: The screening of proposed care immediately upon receiving the notification call to determine if discussion with the treating provider and case intervention is indicated.

Concurrent Stay Review: Ongoing monitoring of a patient's stay in the hospital and collaboration with care providers to ensure medical necessity and appropriateness of care and setting, and timely discharge. To determine if a patient should remain hospitalized for a length of time greater than the pre-certified days.

Utilization Review: The periodic review of the patient=s hospital stay to determine the medical necessity and level of care provided.

Discharge Planning: Evaluation and coordination of services which will be needed following the patient's discharge from the hospital. Discharge planning commences immediately upon notification in selected cases and focuses on promoting timely discharge and a smooth transition to an appropriate cost-effective care setting.

Case Management: A process which involves the timely coordination of quality health care services to meet an individual's specific health care needs in a cost-effective manner. "A collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communications and available resources to promote quality cost-effective outcomes". (Case Management Society of America, 1994)

Large Case Management: For those cases where the illness has been determined to be catastrophic, requiring long term care or complicate care.

High Risk Pregnancy Case Management: If during the initial screening, it is determined that a pregnancy may be a high risk situation, appropriate case management services will commence.

Surgical Procedures and Second Opinions: To assess whether certain surgical procedure are being performed either inappropriately or unnecessarily, in some cases, a second surgical opinion by an unbiased surgeon will be obtained.

Post Discharge Review: On selected cases, a review of charges and procedures to determine appropriateness of care and medical necessity.

Auditing: A unique approach to retrospective auditing of both hospital and provider claims. We have a proven track record of achieving significant reductions and corrections above and beyond the savings that are realized by discount networks, re-pricing services, and utilization management programs as separate entities. By integrating the benefits of all of these other important elements of your cost management efforts, we are able to ensure that the bills that you ultimately pay are an accurate and true representation of the services that were validated and established as medically necessary by your utilization review provider.

WatchNet® PPO Program Network Option: Total Claims Review offers you a value-added alternative to the traditional package of "utilization services plus a PPO". We will assist you in selecting an established and accredited preferred provider network which best meets your membership's demographic and health care needs. Once we have guided you in this analysis and selection process, we will coordinate the entire process with the PPO, so that you receive repriced claims with no additional administrative layers or costs to deal with. It is Total Claims Review's proven experience that our role as the intermediary between the plan and the PPO adds a safety net of accountability on the part of the network. As an unaffiliated and independent review entity, we can work with the providers to ensure the appropriate utilization and medical necessity of the services provided. By removing the potential for a conflict of interest which is inherent in total products provided by the same organization, we give you an added value which delivers both cost and accountability, as well as flexibility in making changes should the need arise.

Pre-Certification, Pre-Notification, Pre-Admission Review, Concurrent Review, and Discharge Planning are all components of the overall Case Management continuum, which is the foundation and substance of effective Utilization Management.