Claims Eval, Inc. leads the external medical review industry with superior customer service, and provides consumer protection on health care coverage disputes as mandated by the Patient Protection and Affordability Care Act (PPACA). When a request for analysis of medical treatment is received, a Peer Review Physician who is state-licensed and board certified in the appropriate specialty is selected to provide an objective, defensible, evidence-based medical assessment of the diagnosis, origin and treatment of an injury.
Reviews include medical necessity, relatedness to injury, treatment solutions, appropriateness of care, and future treatment needs.
Claims Eval’s turnaround times meet or exceed all federal and state requirements.
Standard Reviews are completed in 24-48 hours, and in no case longer than 72 hours from the request, except when time is needed to collect additional medical information, or to allow for peer to peer discussion.
Expedited (same-day service) is available on request
Partnering with Claims Eval, Inc. is easy. For independent, external peer reviews, file reviews, and pharmacology reviews, we create a custom profile to meet each client’s specific requirements. Our support staff provides readily accessible telephone and consultation support from 6 am to 6:30 pm PST.
Patient information and medical records are transmitted through electronic data interface into our state-of-the-art, secure, web-based portal. Each new request is immediately assigned to a specialty-matched Peer Review Physician.
In addition to rapid turn-around time – usually 24 hours or less – our outstanding independent utilization review service provides an objective, defendable, evidence-based analysis of Prospective, Retrospective or Concurrent medical care. Our URAC accreditation mandates adherence to the industry’s most stringent quality assurance, HIPAA compliance, PHI confidentiality and security protocols.
Increase your hospital’s Medicare, Medicaid, and Insurance reimbursements with 365-day, 24-hour access to a broad panel of doctors who determine, within critical time frames, appropriate inpatient admission levels based on experience, judgment and Interqual Criteria guidelines.
Claims Eval understands the importance of concurrent (at the time of treatment) reviews to accurately assess SI (severity of illness) and IS (intensity of service), establishing levels of care and eliminating financial vulnerability under Medicare Condition Code 44.
Medical decision-making in partnership with Claims Eval also eliminates the possibility of Conflict of Interest (COI) in your hospital community, reducing litigation, and improving quality of care to your patients.
If your healthcare organization finds an on-staff Medical Director too costly, or you don’t know how to recruit a candidate with the right experience, a licensed, board-certified Claims Eval doctor might be the answer.
Our physicians act as Medical Directors for plan providers, insurance companies and medical management firms. Our Medical Director Services meet your specific medical needs, from meeting seasonal workload peaks, to covering vacations, to augmenting your internal claims review capabilities.