Case Review Procedure
Preauthorization of Proposed Surgical Procedures:
Cases submitted for preauthorization for benefits for Orthognathic, TMJ, Implant, and other Oral surgery will be reviewed. Submitted documentation will be reviewed. If any additional information is required it will be requested by us to be sent directly to us so we may complete the review. Medical necessity will be addressed. Decisions are based on current science and literature with regards to acceptable and recommended treatments for specific conditions. Plan language will be reviewed to provide coverage in keeping with the intent of the plan. Specific underwriting requirements will be reviewed and followed. Least Expensive Professionally Adequate alternatives will be recommended if appropriate. Reasonable and Customary fees can be assigned to the various procedures if desired. A report will be submitted with the decision and the basis for that decision. Turnaround time for the report from the time all necessary information is gathered will be two (2) days. The report can be submitted by fax, e-mail, or hard copy. The fees for these reviews are per report and listed in the 2003 Pricing Structure.
Review of Denied or Appealed Claims:
Previously reviewed and denied preauthorizations, whether or not we did the original review, will be reviewed on appeal. We can review this case as agent for the company or as an Independent Outside Review to satisfy plan or mandated requirements. The same guidelines as standard review will be applied. Any additional material necessary for the review will be requested by us directly from the provider. We will speak to the provider if appropriate or necessary to complete the review. A report will be submitted with the decision and the basis for that decision. The turnaround time for these reports will also be three (3) days from the time all pertinent information is obtained by us. The fees for these appealed reviews are per report and are in the 2003 Pricing Structure.
Case Management Services:
We will review plan provisions and advise on policies and procedures as relates to Oral and Maxillofacial surgery including but not limited to definitions of covered services, parameters of care, limitations and exclusions, protocol for treatment, e.g. treatment planning and sequencing, requirements for conservative treatment attempts as first approach, etc. We will review and evaluate medical records for potential and pending litigation against either the plan or the provider and present expert testimony as needed. The fees for these services are at our hourly rate or as part of a negotiated full service retainer.