Healthcare
In-patient and Out-patient
Medicare
National Health Insurance Program in the US funded by the Government
In-patient/Hospital Insurance
Hediss Review
Between February-May 10th
Minimum required
Provider/Facility name, Physical Address, Fax number, and Request mode.
Provider
Facilities, Clinics, Nursing Home
Medicaid
Federal and State program that helps with medical cost, funded by the Federal and State.
Part B
Outpatient/Medical Insurance
HCC Review
Begins around June with submission date for the Insurance company in the end of January
Request Modes
Fax, Email, and Mail(5-7 business days)
Payer
Insurance Company, Provider Groups, and ACO's
HEDISS
Part C
Combination of Part A and B.
RADV review
Begins around September/October and submission is end of March
Collection Methods
Mail, Email, Fax, Onsite Scanning, Remote download, Copy service, Provider upload, and Fedex.
Our Objective
To retrieve Medical records from Providers/Facilities/Hospitals, to supply those records to our clients
(Insurance companies, health plans, etc.
HCC
Hierarchial Condition Categories
Part D
Prescription drug insurance.
What is involved
Collecting medical records, reviewing medical records, reporting back to CMS.
Verification Types
Partial, Verification Done, and Send request
CMS
Center for Medicare and Medicaid Services
RADV
Risk Adjustment and Data Validation
Who is covered
Long-term disease and individuals 65 and over.
3 Types of reviews
HEDISS, HCC, RADV
3 types of Non-Progressing Calls
Un-obtained Status, Callback Change, and Data Research