Provider Networks | Utilization Management | Component & Consultative Services

Component Products

Claims Repricing - Ohio Health Choice receives medical and/or hospital claims for services rendered by providers and determines panel status. Ohio Health Choice then calculates the reimbursement for panel providers in accordance with the Ohio Health Choice Fee Schedule. Savings Reports are included.

Special Vendor - Payor has subcontracted another agency to review some special services.

Consultative Services

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 final determination.

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 procedures, etc.


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