Medical Claims Review. Should there be a dispute over a medical claim under the County's self-funded health plan, it shall be resolved in the following manner: The Insurance Appeals Committee shall first attempt to resolve disputes, not related to medical necessity, as outlined in County’s self-funded health plan document(s) claims procedures. If the dispute remains unresolved, it shall then be referred to the separate arbitration procedure that has been established under the County's self-funded health plan. The aggrieved employee and the County shall each pay one-half (1/2) of the cost of arbitration.
Medical Claims Review. STEP If an employee objects to the Insurance Company’s disposition of a claim, the objection must be filed in writing and submitted to the Human Resources Manager. STEP The Human Resources Manager will send a copy of the filed objection to the Insurance Administrator. The Administrator will review the matter and reply to the employee through the Human Resources Manager. STEP If the matter is still not resolved, a meeting will be scheduled normally within thirty (30) days, unless extended by mutual agreement, and will include the Insurance Administrator, a Union representative, and a representative of the Insurance Company who will issue a final disposition of the matter. The Union can apply for arbitration if a meeting is not held within the thirty (30)day time period.
Medical Claims Review. Xxxxxxxx’s clinicians conduct Medical Claims Review retrospectively through the review of medical records to determine whether the care and services provided and submitted for payment were Medically Necessary. Retrospective review is performed when Keystone receives a claim for payment for services that have already been provided. Claims that require retrospective review include, but are not limited to, claims incurred: under coverage that does not include the Preauthorization program; in situations such as an emergency when securing an authorization within required time frames is not practical or possible; for services that are potentially Investigational or Cosmetic in nature; or for services that have not complied with Preauthorization requirements. A retrospective review decision is generally issued within thirty (30) calendar days of receiving all necessary information. If a retrospective review finds a procedure not to be Medically Necessary, the Member may be liable for payment to the Provider if the Provider is Nonparticipating.
