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  • Clinical Review Guidelines
  • Claims Screen Guidelines
  • Diagnosis Guidelines

Clinical Review Guidelines

Saving clients time and money, provide piece of mind when dealing with intricate cases.

In Patient Scenarios
  • All in-hospital lasered patients
  • All cases where total costs minus specific deductible are >$350,000
  • All in-network cases with projected/actual LOS>21 days
  • All out of network cases with >4 day length of stay, total costs >$75,000, or Per-diem costs >$5000.
  • All cases where patient has had >3 acute to sub-acute transfers in 3 month time period
  • All cases where change in medical care plan, i.e. escalating dosages of drugs, is not supported by laboratory or radiology evaluation
  • All cases where payer UR reviewer is unable to elicit plan of care from provider.
  • All cases where plan is unable to get a PPO or non-participating provider discount
  • Admission with projected/actual LOS >7 days: Neonatal Intensive Care
  • Admission with projected/actual LOS >10 days: Long Term Acute Care Facility
  • Admission with projected/actual LOS >21 days: Rehabilitation Facility
  • Admission: Greater than 3 admissions within the last 6 months
  • Total Claim >50% of Stop-Loss deductible (includes inpatient/outpatient, DME, ancillary services)
  • Patient with high resource utilization
  • Disclosure/Illness Date of Onset Issues
  • PRN cases at client discretion

Retrospective Medical Review
  • All the above scenarios, except for the 50% notification cases.
  • All cases lacking Case Management or Utilization Review Notes where case management or utilization review is indicated but not performed

Specific Clinical Scenarios
  • Patients receiving IV gamma globulin for any condition other than ITP or hypogammaglobulinemia
  • Other experimental/investigational drug/procedure questions
  • Patient in LTAC and no evidence of vent weaning or daily physician intervention
  • Questions regarding dosage/duration of therapies
  • Questions regarding off-label usage for FDA Approved Drugs


Claims Screen Guidelines

Hospital Out of Network Claims:

Hospital Out of Network claims > $50,000

Hospital In-Network Claims:

Greater than $50,000 for PPO discount < 10%

Greater than $100,000 for PPO discount 10-20%

Greater than $200,000 for PPO discount >20%

Inpatient Daily Bed Rate Charges:

  • ICU Bed Rate >$4,000/day
  • Med-Surgery Bed Rate >$2,500/day

Implantable Devices-Other Carve Outs:

> 50% of total billed charges

Chemotherapy/Radiation Therapy Claims:

All individual claims greater than $15,000

Surgery/Chiropractic claims:

Unlisted or New CPT codes

Claims with extensive laboratory/pharmacy charges

Dialysis Claims:

  • Monthly Dialysis Charges > $10,000
  • Individual Dialysis Charges > $2,000
  • Erythropoietin Charges (EPO) > $1,000

All Inpatient Psychiatric Claims
All other claims at your discretion

Do you have everything required to assess the claim? Is there a UB92, Itemized Bill, and Operative Report? All the documents are key to assessing a claim for adjudication. Remember, every claim is unique and all factors must be considered before adjudication. There is no single best course of action on claims even for the same patient from the same hospital during the same admission.


Diagnosis Guidelines

Below is a list of potentially catastrophic diagnoses that could require Case Management and close review. Weekly/Monthly reports should be run to identify new patients meeting these criteria. Be sure to request assistance immediately once you are notified that a member has an illness, injury, or requires services listed below the table.


Leukemias, Carcinomas, Hemophilia

Aneurysms Cerebral Injury-Any Cause


Cerebral Hemorrhage


All Transplants

Acute/Chronic Hepatitis/Cirrhosis/Liver Disease

Cystic Fibrosis/COPD


Adult Cardiac Arrest, Adult Resp. Arrest, Vent Dependency

Chronic Low Back Pain


Psych Condition Requiring Hospitalization

Burns-> 20% Tba Or 2Nd-3Rd Degree

Valvular Disease



Spinal Cord Injury


Major Chest/Abdominal Procedures

Neonatal Cong. Abnormalities

Birth Trauma, Premature Birth

Newborn Resp Arrest, Neonate/Infant Resp, Distress & ICU > 7 Days

High Risk Pregnancy, Preterm Labor


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