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AUDIT & REVIEW SERVICES - Utilization review Services - Provider-specific auditors (benefit-specific), comprehensive of a provider's complete practice - Resource-based Relative Value Scal Provider Fee Schedual - Audits to assure correct process is followed for determining network discounts and allowances for out-of-state providers - Audits to determine that the correct network is utilized for out-of-state providers - Audits to determine timelines of claims payment and other provider satisfaction issues - Review and respond (or provide recommendations) to appeals related to audits - Duplicate Payment - Payment over and above Contractual Rates - Other External Payments |
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