Our medical criteria substantiates findings, minimizes appeals, and supports recovery.
We use qualified, professional staff, appropriate criteria, practice guidelines, regulations and rules, and knowledge of prevailing standards of care in the specific state or community to make the most accurate review determinations. Likewise, our clinical staff use nationally recognized, program-relevant medical and utilization criteria to produce detailed and well-documented findings that minimize appeals and help providers improve their process.
We have an established nationwide network of credentialed physician reviewers to conduct peer-to-peer medical specialty review of cases that do not meet screening criteria applied by nurse reviewers. The peer review panel is utilized when outside expertise or assistance is required.