Our Managed Care Claims Examiners consist of dedicated teams of experienced Claim Examiners. Deep experience in all lines of business producing exceptionally high quality adjudication.
Our Benefits team provides clients with a standard benefit plan setup & interpretation, with standard event classes & benefit rules. We handle benefit calculations, calculating OOP from plan cost & tracking benefit costs.
Our Eligibility Specialists support a stringent process of verification of member eligibility records and update of member records by verifying Eligibility details online from Health Plans and State enrollment records.
Our Review team performs an increased level of research, investigation and independent evaluation of Appeal data in compliance with standard protocols and overall clinical objectives.
The HCC team comprises of expert, clinically-trained coders (CPC, CPC-H) and physicians who engage in highly efficient chart reviews to recover valuable ICD-10 codes for accurate coding of the member population risk level.
We offer support to New MSO buildouts across three key areas including System Evaluation & Selection, Process & Org Design, Delegation contracting with P&P design, and Pre-delegation readiness support.
Administrative Support For Medical Management
The Calibrated UM Program offers clinical and non-clinical levels of prospective, concurrent, and retrospective reviews to ensure quality-based, cost-effective management of healthcare resources.
Calibrated employs trained clinicians to partner with hospitalists or attending physicians to facilitate a safe and effective discharge plan from an inpatient or skilled nursing level of care. Clinicians perform concurrent review to determine medical necessity of admission, continued stay, and appropriateness of level of care.
Calibrated aims to support hospital revenue cycle recovery programs through aggressive appeal management for medical and behavioral acute care denials.
Calibrated can provide clients with specialty referral tracking services that include assisting dependent members with specialist appointment scheduling, confirming appointment adherence, and assistance with provider exchange of information through the contact center
Calibrated aims to support clients in the accurate processing of denial, modification, or pend notifications to ensure communications meet regulatory guidelines in terms of content, form, and timeliness
Calibrated clinical documentation improvement team reviews retrospective ED claims to ensure the appropriate level of care for cost effective use of healthcare resources.