Medical Case Management Services

The Vendor is required to provide medical case management services to provide medical case management and utilization review and payment of uninsured employer, and bankrupt self-insured employer claims in accordance with Statutes.
- The Special Claims Unit, is currently administering approximately 200 litigated claims and 600 medical only claims. Currently, 300 files are assigned for medical review.
- Special Claims Unit Files
•    Vendor will ensure Special Compensation Fund (SCF) medical ability to minimize costs while providing timely access to quality health care services for its claimants with work-related injuries.
•    Provide timely and accurate processing and continuous review of medical care received by injured claimants to ensure reasonableness and medical necessity.
•    Ensure that any type of functional abilities prescribed for injured claimants are consistent with the type of injury, the diagnosis, and the treatment plan.
•    Review all medical decisions to ensure that they are appropriate and consistent with the treatment plan.
•    Ensure that medical providers are reimbursed according to the fee schedule established by administrative rules and within mandated timeframes and to provide payment of hospital charges according to administrative rules, including calculation of Diagnostic Related Group (DRG) payment. Late payments may result in penalties at the vendor’s expense. Vendor will be responsible for costs and legal fees associated with disputes where it seeks to establish future medical bill review and payment process standards.
•    Meet with SCF staff and state agency personnel upon request, to plan the direction and disposition of the medical management of employees' claims.
•    Accept medical service invoices and records via electronic transaction processing.
•    Administer coordination of pharmacy services.
•    Provide flat file associated with billing information on a monthly basis that would allow application of costs of bill processing fees to be allocated to individual claim file without manual manipulation of billing data.
•    Provide monthly report of the breakdown of billing amounts by organization level for payment to vendor of monthly service fees
•    Provide weekly aging report of outstanding medical payments that have not been processed for approval or denial.
•    Provide monthly reports of bills received based on media format, i.e., electronic, paper, etc.
- Second Injury Program
•    Vendor will review medical services for pricing accuracy only for second injury program claims. No payments are to be issued.
•    Review all medical treatment and services to ensure that they are appropriate and consistent with the treatment parameters.
•    Review bills according to the fee schedule established by administrative rules and within mandated timeframes and to recommend reimbursement amount for specified hospital charges according to administrative rules, including calculation of Diagnostic Related Group (DRG) payment.
•    Review pharmacy services if applicable or as requested.
•    Provide SCF with Explanation of Benefits (EOB) for referred bills.