Empire State Medical, Scientific and Educational Foundation

Providing High Quality Medical Peer Review & DRG/Coding Validation

Independent External Appeal/Dispute Resolution Review

The Foundation 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 30 years’ experience in utilization review, quality
assurance and coding and 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 of:

  • Admission to acute level of care
  • Admission to observation level of care
    • Admission to exempt unit (acute medical rehab; psychiatric, etc.)
      • Length of hospital stay at acute level/subacute level
      • Procedure performed in an acute or non-acute setting
      • Readmission case 

 

DRG Assignment based on:

  • Principal diagnosis
  • Secondary diagnosis
  • Principal procedure
  • Secondary procedure
  • NYS Grouper Logic
  • Medicare Grouper Logic

 

The Foundation ensures that all cases submitted are:

  • Reviewed by a Board Certified Physician Specialist 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
  • Result in 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 reviewer

 

For more information regarding the external review/dispute resolution process, please contact 1-800-437-8134, or download our application.

APPLICATION (Link)