Bill Review

Bill Review

Our Nextrum platform uses rule-based analytics that assist in the review of provider bills. Nextrum recommends reimbursement according to each state’s unique fee schedule, Usual/Customary and Reasonable Fees and if appropriate, PPO. Nextrum is integrated with a utilization management database to assure that bills are re-priced with knowledge of each bill’s history if appropriate. Client bill review questions can be directly answered by PRIZM’s call center versus going directly to the adjuster, reducing call volume and increasing adjuster efficiency. This service is offered complimentary to our clients.

Key Features of our Bill Review Solution:
  • Application of defensible Auto PPO Discounts
  • System can be configured to adjudicate against client-specific rules
  • Explanation of Benefits (EOBs) are generated and forwarded to the insurance adjuster in a paperless and real-time environment
  • Trained staff responds in a timely manner to adjuster’s questions and concerns through a two-way notes system
  • Standard and ad hoc reporting – all claim information and data, including vendor information, CPT codes are available to the client real-time through our reporting platform
  • PIP Ledger – automatically keeps track of indemnity dollars spent, while calculating deductibles and co-pays
  • Built-in auto calculation on interest payments
  • Payer Page – purpose-built focused area for clerical staff from which to make payments 


Our in-house nurses conduct hospital audits and provider bill audits to determine accuracy, medical necessity and causality. In addition, the level of care and length of stay are reviewed against standardized guidelines.

Key Features:
  • Determine appropriate method of review (on site or off site) based on state-specific guidelines and carrier-specific polices
  • Request medical records and billing information
  • Complete audit including utilization and financial negotiations
  • Recommend a peer review, if warranted
  • Apply PPO if appropriate
  • Complete report with signed Letter of Agreement from the provider

Code Review

PRIZM's Certified Coders review specific Current Procedural Terminology (CPT) codes, selected by our clients, for appropriate coding. We continually monitor usage of codes, provider billing trends and provide recommendations to our clients.

Key Features of Our Code Review Solution:
  • Clients are provided a suggested list of codes that can be selected for review
  • Identified codes can be flagged in our system for review or referred to the adjuster
  • A certified Coder or Nurse reviews identified codes for correct coding initiatives
  • Modification of code(s) as needed with resulting EOB reflecting changes
  • In-depth documentation of coding recommendations can be provided based upon client need


State-Specific Capabilities

All states:

  • Automated Payment Ledger
  • Application of Termination of Benefits based on IME outcomes
  • Application of Peer Review outcomes to billing



  • Automatic adjudication of bills against treatment plan outcomes
  • Application of NCCI edits and MUE guidelines
  • Use of Preferred Networks for Pharmacy, DME and Diagnostics



  • Fee Schedule Affidavits and Testimony
  • Automatic Delay Process
  • Editable NF-10
  • HCRA Surcharge calculations
  • DRG Validations performed by a nursing professional



  • HB119 Automation
  • Application of NCCI Edits
  • Automatic denials for non-licensed providers
  • Systematic reserve of $5,000 in benefits for emergency services and care