The Foundation is currently operating a dispute resolution process to resolve payment disputes involving medical necessity and/or DRG assignment.  This program offers a quick and inexpensive avenue for providers and payors to resolve payment disputes involving medical necessity and/or coding/DRG assignment.  With over 22 years experience in utilization review, quality assurance and coding and DRG validation, the Foundation ensures an accurate resolution of all disputed issues.  Providers and payors agree contractually to designate the Foundation as their 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

DRG Assignment based on:

   •Principal diagnosis
   •Secondary diagnosis
   •Principal procedure
   •Secondary procedure
   •NYS Grouper Logic
   •Medicare Grouper Logic
   
The Foundation ensures that all dispute resolution reviews 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 criteria
   -Result in a fair, unbiased decision that is
    substantiated by the medical documentation
    submitted for review
   -Are resolved quickly and within contracted
    timeframes
   -Are handled in a manner to ensure the
   confidentiality of all medical information reviewed

For more information regarding the dispute resolution process, or to initiate a review, please contact 1-800-437-2234 or download our application.

Application