ESMSEF is currently operating an independent external appeal/dispute resolution review program to resolve payment disputes involving medical necessity and/or DRG assignment. This program offers a non-biased mechanism for providers and payors to resolve payment disputes involving medical necessity and/or coding/DRG assignment.
With over 40 years’ experience in utilization review, quality assurance and coding/DRG validation, the Foundation ensures an accurate resolution of all issues submitted and that all reviews meet the stringent URAC standards. Providers and payors agree contractually to designate the Foundation as their external appeal/dispute resolution agent. Issues reviewed include, but are not limited to:
- Medical necessity
- Experimental/Investigational
- Readmissions
- Level of care
- Coding/DRG assignment
ESMSEF ensures that all cases submitted are:
- Reviewed by a board-certified physician currently in active practice who has medical expertise on the issue under review
- Reviewed by a physician specialist with no conflict of interest relative to the case
- Reviewed referencing nationally recognized medical criteria
- Reviewed referencing nationally recognized coding guidelines
- Providing a fair, unbiased determination that is substantiated by the medical documentation submitted for review
- Resolved quickly and within contracted timeframes
- Are handled in a manner to ensure the confidentiality of all medical information reviewed