Retrospective Utilization Review - Initial notification
of rendered services made to Ohio Health Choice after services have been rendered, or outside the time frame required per benefit design, and review for medical
necessity is performed retrospectively.
Predeterminations - Prospective review to determine medical necessity for procedures which are potentially cosmetic or non-covered. This service includes verification of benefits/eligibility for said procedures prior to
Off-network Access Review - Prospective review to
determine medical necessity for services obtained outside of the PPO network based on current network availability and scope of service required.
Billing Guidelines - Analysis and recommendations
related to provider billing; i.e., CPT guidelines and
reimbursement methodologies, multiple/complex