1. Provide optimization of billing for laboratory services. a. Identify information derived from historical claims. b. Identify certain criteria where claims could be pended or put on hold for processing. c. Send claims files to CareOregon for review. d. Provide trend reductions. e. Reduce downstream costs. f. Improve overall measures of quality. g. Identify new opportunities for savings. h. Provide reimbursement management. i. Evaluate tests for patients. j. Provide a clinical team to review appeals and support peer review requests. k. Provide support for denials. 2. Evaluate current state of laboratory testing. 3. Manage the use of testing by determining when a prior authorization is required from a physician before a test can be ordered. 4. Review clinical evidence and medical necessity to determine outcomes for prior authorizations. 5. Help develop policies that include determining coverage, reimbursement, and claims payments, i.e., control testing by controlling the funding and payment for lab services. 6. Guide physicians toward clinically actionable tests for members. 7. Improve result interpretations and treatment decisions. 8. Improve lab efficiency by reviewing lab protocols to ensure robust policies are followed. 9. Assist in CPT code identification and usage, facilitating full reimbursement for lab services. 10. If CareOregon identifies any claims (such as Covid blood draw and rapid testing) for the Proposer to review, Proposer shall coordinate efforts to identify this criteria. CareOregon turnaround time of 5 business days for review must be met.
