Services

Group Health

Let the Experts Take a Look®

CareWorks Managed Care Services offers a wide variety of programs and services that review and evaluate claims.  Our vast experience performing in performing independent peer review in the group health, disability and pharmacy sectors has allowed CareWorks to develop best practices, which are applied to meet the needs of individual clients.

When you partner with CareWorks for independent peer review you access the nation’s largest multi-line provider of independent, evidence-based medical peer review and related services, with access to a combined national panel of more than 1,200 board certified and actively practicing credentialed reviewers, our expert reviewers will focus on your needs.

CareWorks’ URAC accredited, independent peer review division completes over 50,000 reviews each year for more than 400 clients, including BCBS plans, Managed Care Organizations, PBMs, Disability, and Auto-No Fault insurance carriers as well as Self Insured Employers, Taft-Hartley plans and Federal and state organizations.

What We Offer:
  • CareWorks has become the leading independent peer review organization by:
  • CareWorks’ Group Health Services available include:

  • Focusing on the individualized needs of clients while using sound clinical expertise and evidence based medical guidelines.
  • Recruiting a highly-qualified panel of credentialed reviewers that allows us to offer matching to the subspecialty level.
  • Creating a case processing system that allows us to remain timely for all types of reviews.
  • Emphasizing and demonstrating superior customer service.
  • Establishing a multifaceted quality assurance and quality improvement program to measure and improve the quality of products and customer service.
  • Possessing the financial stability and resources that enable CareWorks to meet all client obligations.

  • Appeals – CareWorks reviews previously denied services and provides expert advice for appeals.  Reviews include medical necessity, cosmetic, and investigational / experimental procedures and treatments. The reviews meet URAC, NCQA, Federal, and State legislative requirements.
  • External Review (State & Federal) - CareWorks is certified as an IRO in the following states: Arkansas, Colorado, Georgia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Nevada, New York, Ohio, Oklahoma, Pennsylvania, South Dakota, Washington, Wisconsin.
  • Retrospective Review - CareWorks provides retrospective review to assist with resolution of payment issues. The review includes resolution on issues of bundling, unbundling, up-coding, and application of Fee Schedule / UCR as appropriate.
  • Prior Authorization / Pre-Certification - CareWorks reviews authorization for inpatient hospital stays, procedures, and medications.  Each review is performed by either a generalist or specialist depending on the claim’s need.  Reviews are typically completed in 48 hours or less.
  • CareWorks reviews authorization for inpatient hospital stays, procedures, and medications. Each review is performed by either a generalist or specialist depending on the claim’s need.  Reviews are typically completed in 48 hours or less.
  • Fraud Review - CareWorks assesses patient care fraud through our independent review services. Fraud review provides a client with an objective assessment of all aspects surrounding the suspected issues.  The review assessment typically includes a review of multiple patient charts and a summary overview of the fraud or treatment pattern abuses found.
  • Medical (Forensic) Expert - CareWorks’ forensic medical advisory services are ideal for actual or potential legal proceedings such as medical malpractice cases.  CareWorks connects expert witnesses and litigation support specialists to law firms, private practice attorneys, insurance professionals, and other companies in both public and private sectors. Reviewers are available for depositions and court appearances.
  • Special Projects - CareWorks also provides a range of customized special projects and services including:
    • Policy/Criteria Review
    • Guideline Reviews
    • Research Studies
    • Telephone Conferences

A truly effective managed care solution

Our comprehensive array of managed care services deliver the right results for our clients and their injured workers.

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