Claim Review Process

Each claim is reviewed (re-adjudicated) by the PPC reviewer with findings recorded on our claim review software.  The Claim Administrator is always given the opportunity to review the errors and give a response with the expectation that it be backed up with appropriate documentation.  PPC and the Claim Administrators will work together to attempt resolution of every claim issue.  This protocol is intended to facilitate the process of building a consensus on the review findings.

We will document the claim review process by producing a Medical Claim Review Report. This report will document the errors identified, the accuracy of payment, the types of errors, and the trends and recommendations for improvement.