Le CYR Consulting
Professional Services
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Complex Medicare claims/prior authorization requests require the review of medical record documentation to determine the reasonableness and necessity of the billed service in accordance with Medicare rules and regulations. The reviews are performed by specially trained clinical staff using various methods to track the assignment, progress, and resolution of claims/cases. For complex claim reviews, the Companies are required to use Registered Nurses (“RNs”). Clinical decisions will be based on CMS policies/procedures defined in the CMS Internet-Only Manual (IOM), Company policies/procedures, Title XVIII of the Social Security Act (Section 1862), generally accepted standards of medical practice, clinical knowledge, contract guidelines, applicable Code of Federal Regulation guidelines, or other relevant statutory authority as applicable. Our staff will perform this work for Medical Reviews, Appeals, and/or Prior Authorization requests.
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