SERVICES AVAILABLE THROUGH CFMC

NETWORKS

In addition to CFMC’s statewide cost effective networks:

• Preferred Provider Organization (PPO)
• Exclusive Provider Organization (EPO)
• Worker Compensation Organization (WCO)

The following services are offered:

CLAIMS REPRICING

CFMC simplifies the administrative process for claims repricing, offering multiple flexible repricing options to suit clients’ individual needs and capabilities, including Electronic Data Interchange (EDI).

Repricing Options

• Electronic claim transmission via (EDI) by Payor or Clearing House for seamless administration
• Access to CFMC's web-based Repricing System to maintain exclusive control over the claims process

Accurate & Timely Repricing

• Real time pricing on CFMC’s web-based Repricing System
• 24 hour claims turnaround for Professional claims via EDI
• 48 hour claim turnaround for Hospital and Facility claims via EDI
• A 99% accuracy rate and timely re-pricing means efficient administration and rapid claims payment

With so many choices, it's easy to make claims repricing work for you.

THIRD PARTY ADMINISTRATION

Selected Foundations serve as Third-Party Administrators (TPA) specializing in the administration of self-funded and fully-insured health benefit plans. The Foundation TPAs offer efficient and prudent claims processing, a full range of informative management reports to help track utilization costs and savings, accounting services, reinsurance billing and assistance in plan document preparation.

Foundation TPAs also provide a vehicle to access managed health care systems and comprehensive cost containment programs.

Foundation TPAs are service-oriented organizations whose business philosophy promotes excellence in performance, service to its clients and a customer service commitment.

UTILIZATION MANAGEMENT

Utilization Management (UM) Programs are available through the UM vendor of your choice. Utilization Management programs apply industry established criteria and standards for medical necessity and enables plan provision compliance. Utilization management functions are performed by nurse review analysts. Additionally, physician peer review is available and performed by respected local physicians.

Services available through these vendors may include any of the following:

• Prospective Review
  • Inpatient hospital admissions
  • Outpatient surgical procedures
  • Home health services
  • Durable medical equipment
  • Therapy programs (physical, occupational, speech, acute cardiac and sub acute rehabilitation)
  • Diagnostic studies (MRIs, CT scans, vascular and neurological studies)
  • Hospice care
• Second Opinion And Prior-Authorization
• Concurrent Review (review of services as they occur)
• Retrospective Review
• Case Management
• Disease Management