PFMC Medical Review

Health plans and self-insured employers can reduce the cost of their claims by using PFMC’s medical review services. These services are available to all clients regardless of which provider network they use. In-specialty, physician-level review is available for claims payment determination, utilization review, and referral authorization. (See ‘specialties reviewed’ below for a complete list of available specialties.) Types of issues addressed include:

• Claims and CPT coding based on medical records and supporting documentation.
• Appropriate relative value units based on the CRVS scale, or reimbursement recommendations based on a sampling of customary allowances for commonly performed procedures.
• Medical necessity, customary billing practices, and appropriateness of care rendered.

For clients who use the CFMC provider network, PFMC can provide full in-network claims repricing services. We examine each claim to ensure that the CPT codes are appropriate, that services have not been upcoded or unbundled, and that correct discounts have been applied. Our turnaround time in most cases is three to five working days.

Specialties Reviewed

In-specialty peer review is available from PFMC for the following medical and ancillary specialties:

Pediatrics (including neonatology)
Pediatric endocrinology
Pediatric ophthalmology
Physical medicine
Physical therapy
Plastic and reconstructive surgery
Podiatry
Psychiatry
Pulmonary diseases
Radiation oncology
Radiology, diagnostic
Rheumatology
Surgery, cardiovascular
Surgery, colon and rectal
Surgery, general
Surgery, peripheral vascular
Urology