OMMR
Possible vendor management for 4 months of treatment with Dr. *****
What is a chiropractic peer review?
PRO stands for...
What is Peer Review Organization
This is the letter sent to the providers when a peer is initiated (ML#)
What is ML 211?
This is how long after the referral we complete the post-referral check in/template.
What is 3 weeks?
This is the ML we use to request reimbursement.
What is the ML215?
Question to ask a provider when determining if a peer review is warranted.
What are complicating factors?
Why haven't the pain levels reduced?
Have you referred them out for any diagnostic testing?
Have you referred them out to any other specialties?
Is there a reason why they are not following your treatment plan?
A peer review addresses this for ongoing treatment.
What is reasonableness and necessity of treatment.
These are the vendors we use for peer reviews.
What are
If you receive new bills from new treating providers, do you need to share them with the vendor?
What is Yes – we will to allow the PRO to have a holistic view of all treatment. Even if the new bills/provider are not subject to the peer review, we should still send the bills to the provider.
You received a completed peer review back. How long do you have to send out the report with the applicable letter?
What is :
Is PA Act 6 vendor management possible with this provider?
Chiro Chiropractic
1234 Main Street
Anywhere, WV 12345
What is no- this is an out of state provider.
This is where you put "why" you are referring for a peer review.
What is the Pre-Referral Template.
These are the screens that need to be updated when completing a peer referral.
What are:
Add vendor to claim,
update BT screen to No and include name of vendor/date of referral, and
Update UDF in MDP to IME Requested and fields for Peer specialty and name of medical management vendor being used.
You are completing a post-referral check in after referring a chiro peer review. You received a bill for cervical and lumbar MRIs which were referred by the chiro. Should you put this provider on notice at this point?
What is Yes – the diagnostic study is referred by the chiro and is subject to the peer review. The letter should be sent to the facility and biller in the fastest manner possible (e.g. fax)
What screens have to be updated after we receive a completed report?
What are:
Specialties for vendor management on a policy with $50k limits and 12 months of PCP visits for prescription renewals and 8 months of chiropractic treatment.
What is a chiropractic and MD peer.
This is where you put contact attempts/made with all known providers to confirm treatment and referral status.
What is the Pre-Referral Template.
Can you share only pictures of damages to our vehicle with the vendor?
No. If we only have pictures of our vehicle, we cannot share them (except for SVA). In order to share pictures, you must have pictures of the damage to any/all vehicles involved in the loss in order to avoid bias.
Are you required to send new bills to vendor while peer review is being completed?
What is Yes – bills should be regularly shared with the vendor to ensure the PRO has the most up-to-date records to make an appropriate determination.
This is how long the vendor have to send the report to us once they receive it from the PRO.
What is 3 days.
What improvements are you experiencing with the plan of care?
If you aren't improving, has the doctor discussed trying anything different? Diagnostic testing? Referring you to another specialty?
What are questions to ask the insured when determining if a peer is warranted.
IV and CV pictures and/or police report are sent to which party during the peer review process.
Who is the peer review vendor.
We are in the process of completing a chiro peer review. The patient was referred to an EMG by the chiro. We have bills from the physical medicine & rehab doctor who did an initial evaluation and performed the EMG. Are those bills subject to the peer review and should they be put on notice?
No – if they did an entirely new evaluation of the patient, those bills will not be subject to the peer review because the treatment was rendered by a practitioner that is not of like specialty.
Factors you consider when determining if a peer review is still appropriate at the check in point.
Depends on the policy limits and the specifics of the accident. You should look at any newly received bills for treatment status/frequency, any new diagnostic studies, and new specialties.
If treatment is not medically reasonable or necessary but we have already paid for bills, how many days back can we request reimbursement?
What is we can request reimbursement for bills that are received and paid within 90 days of referral.