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Manages threshold rules to drive clinical reviews for proper bill documentation and causal relationship within medical bill auditing.
Allocates and deallocates patient deductibles, co-pays and policy limits after medical bill review. Supports the sharing of deductibles and co-pays across multiple injured parties as regulated by state guidelines. Enforces overall policy limits for individual claims and calculates late interest payments to providers and facilities for overdue bills.
Bill Negotiation Manager
Manages threshold rules to drive the negotiation of out-of-network bill negotiations. Contains historical negotiation results by provider to maximize current negotiations.
Bill Review Manager
Encompasses a complete set of cost containment rules to enforce during medical bill review. Additional rules based on the outcomes of almost every Medlogix® service and associated manager is also seamlessly integrated as part of the bill review manager.
Care Plan Manager
Captures all information related to a pre-certification request. Analyzes current and past claims activity to present in a user friendly research tool for capturing medical director review decisions and rationale. These medical decisions are used to auto-adjudicate bills during medical bill review.
Manages all the outcomes derived from our field case management, telephonic case management and large case management services to utilize within the utilization management, pre-certification and medical bill review services.
Similar to email, except secure and tightly integrated into the history of the claim, the communications manager provides a mechanism for Medlogix® and clients to communicate about the workflows of daily claims management. Messages can be acknowledged and answered when appropriate. The communications manager can also send emails that link directly to MyMedlogix™ internal messages.
CPT Rule Manager
Allows for system and/or client-specific rules to be created for CPT codes to be either auto-adjudicated during medical bill review or flagged for comprehensive nurse code review.
Tracks all diagnoses related, unrelated and pending determination to establish proper causality for accurate pre-certification and medical bill review – supports both ICD-9 and ICD-10.
Organizes claim documents from all services by type, provider, specialty and date. Supports uploading new documents and downloading existing documents into organized packets of information optionally including fax receipt confirmations.
Manages the first report of injury from initial triage through provider scheduling, follow-ups and eventual state regulatory reporting as required.
Prospective, concurrent and retrospective pharmacy benefit management to control drug costs within medical bill review.
Manages access to CHN PPO Network as well as access to more than 725,000 providers nationally through Medlogix® PPO affiliated partner networks.
Professional Review Manager
Captures all information related to scheduling and securing IME and peer review outcomes. Outcomes are loaded into the Utilization Review Manager for auto-adjudication during medical bill review.
Analyzes historical provider data captured during medical bill review. Data is ranked in over a dozen categories to reveal critical insights and trends that may be related to suspicious and potentially fraudulent activity. This tool also compares providers against their peers to see how they rank in numerous categories.
Provider SIU Manager
Supports the ability to designate a provider as under review by a Special Investigation Unit (SIU) for possible fraudulent or other suspicious activity. Client-specific rules control how services are then handled during pre-certification and medical bill review.
Robust data warehouse techniques unify all claims data and service outcomes to deliver all the information you need quickly and easily. Assures that all state regulatory reporting guidelines are satisfied. Provides access to numerous reports in several easy to use formats within the following categories:
Utilization Review Manager
Consolidates outcomes from IMEs and Peer Reviews to auto-adjudicate bills during medical bill review.
Shows every job currently active from all services organized by client, process, status and age. Includes interactive drilldowns into real time user activity.