KePRO Appeals and Medical Necessity Review Services for Public Programs
KePRO performs independent medical necessity, as well as first and second level
appeals review of denied services for fee for service and managed care enrollees.
We apply nationally recognized criteria to ensure that enrollees receive the care
they need in the most cost effective settings. (bookmark to info below)
Using nationally recognized criteria ensures you that our review determinations
can withstand scrutiny and simultaneously secure the integrity of the review process.
And we support the fair hearing process by preparing documentation and testifying,
if necessary.
We are well-versed in federal and state review regulations, and adhere to all plan-specific
provisions. We are also URAC accredited in health utilization management, assuring
you that our review processes are efficient.
KePRO has over a quarter of a century of experience complying with criteria, regulations,
and policies in the Medicaid, Medicare, and other public program arenas. We efficiently
and effectively make determinations on all review types in all review settings and
for all services.
KePRO performs first and second level appeals review and grievance services. Our
extensive pool of credentialed peer reviewers provides independent decisions to
support or recommend modifications or approval of denied services. We adhere to
all conflict of interest requirements, using a physician of the same or similar
specialty who has no formal relationship with the insurer, patient, or involved
physician/ provider.
We also support the fair hearings process. We prepare documentation to support our
upheld decision and provide expert testimony when required.
KePRO provides critical appeal services for the Bureau of TennCare. TennCare is
the State's Medicaid waiver program that provides health care for 1.2 million Tennesseans.
It is the only program in the nation to have its entire Medicaid population enrolled
in managed care. Medical, behavioral and long-term care services are covered
by at risk managed care organizations in each region of the state.
Promoting Program Efficiency and Cost Effectiveness
We provide the following services that help control costs and lead to greater operational
efficiencies for the Medicaid program:
- Medical necessity, clinical contraindication and hardship reviews
- Medical testimony at fair hearings
- Quality improvement
- IT services
- Analytics expertise
- Training
For cases meeting Bureau of TennCare appeal criteria, we provide medical necessity,
clinical hardship, and contraindication reviews. Our medical experts render professional
opinions as to whether recipient appeals satisfy applicable clinical and legal requirements
of medical necessity as defined by the Bureau of TennCare. Our staff physicians
also provide testimony at fair hearings to support denial determinations.
KePRO physicians also monitor and analyze trends in appeals to ensure TennCare’s
MCOs are relying on and correctly applying guidelines/criteria, which supplement
TennCare rules in supporting denials. We also monitor the MCO’s guidelines/criteria
for appropriateness and correctness in their application, as well as to ensure,
where possible, that they are based on principles of evidence-based medicine and
community standards of care. We communicate with TennCare’s Office of Medical Directors
and executive management the results of this monitoring and analysis to ensure that
they are aware of identified issues. We also consult with TennCare on rule changes,
as necessary
To put KePRO’s medical necessity and appeals review services to work for your public
program, call our business development professionals at 1.800.222.0771 or
contact them directly.