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:

Audits

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:

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:

 

State-Specific Capabilities

All states:

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

 

NEW JERSEY

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

 

NEW YORK

  • Automatic Delay Process
  • Editable NF-10
  • HCRA Surcharge calculations
  • DRG Validations performed by a nursing professional

 

FLORIDA

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

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