![]() Return documented decision electronically to Companies via established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews).This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to educate the providers on how the review decision was made Complete the documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template to be provided by Companies.Companies will review the three-claim sample for accuracy of claim decision and will make and return decisions to the MRS within 24 hours or less.Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making. ![]()
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