Claims

Simple and Efficient Proccessing

PremierOne Plus MSO’s claims department simplifies and make your claims processing prompt and efficient. All our staff are very experienced with Medicare, Medi-Cal, and Commercial regulatory requirements and time guidelines, simplifying and customizing claims processing. We provide flexible solutions that customize client payments based on each specific Health Plan contract, Provider Contract, member eligibility and member benefits. Our MSO Claims Management System automates the claims submission and payment process by logging, adjudicating, and pay claims. Our systems allow you to submit claims electronically, through our Claims Submission web based platform, thus substantially reducing processing times. Providers can also review statuses and histories of their claims and payments.

Our MSO Claims Management System automates the claims submission and payment process by logging, adjudicating, and pay claims. Our systems allow you to submit claims electronically, through our Claims Submission web based platform, thus substantially reducing processing times. Providers can also review statuses and histories of their claims and payments.

Credentialing

Trained Credentialing Specialists

Enrollment and Credentialing can become a hassle that could even interfere with the provision of quality health care. PremierOne Plus MSO offers a customized service that helps your organization work with all the major Health Plans in California. Our trained credentialing specialists complete the plan applications for your providers and work with the health plans after submission until participation is attained. If you choose to use our physician billing services as well, inclusion of provider numbers for claims submission is easily integrated.

Our Credentialing Department maintains IPA's and Medical Group provider files current with NCQA and Health Plan credentialing standards.

Financial

Revenue Management

Our finance department prepares the budget and financial forecast for your IPA/Medical Group. Our Finance Department evaluates the profitability of each of the health plan’s contract, its products, risk pools and assists the outside independent accounting firm in complying with federal and state regulatory requirements.

PremierOne Plus offers revenue management physician billing and in-house collection services.

Member Services

Always Up-to-date Member Information

The Member Services/Eligibility department works with our contracted client’s health plans to provide the most up- to-date member information for our physicians, claims, and utilization management department.

Management Information Software/Systems

Advanced Computer Software

Utilizing advanced computer software helps facilitate information to our providers and contracted health plans. PremierOne Plus has co-developed a web-based management system that allows providers the ability to submit claims and authorizations; check claims status, eligibility, and authorizations.

Our MSO Management Software assists physicians’ practices with implementation, maintenance, and support of the practice management, Electronic Health Records Systems (EHR). With ample experience with a plethora of EHR systems, PremierOne Plus MSO integrates and maximizes the potential for savings and secures compliance to receive applicable government incentives.

PremierOne Plus MSO takes the pressure off of physicians to maintain and understand complex networks and systems, and allows them to focus and streamline patient care.

Provider Relations / Contracting

Our MSO addresses and resolves any concerns that Providers may have

Knowing how important Provider Relations and Contracting is, our PremierOne Plus MSO’s provider relations department addresses and resolves concerns that providers have. Our team will assist you in complying with IPA policies and procedures, health plan audits, and regulatory changes.

Experienced Provider Relations staff are available to help you with claims submissions, authorization process, and other vital operational information while lunch is served.

Utilization Management

Fast and Accurate Authorization Requests

PremierOne Plus MSO’s UM Department provides fast and accurate way to handle authorization requests and coordinate managed cared with the client’s Medical Director. Physician Profile referral statistics and hospital bed days reported monthly gives the IPA's a current overview of their UM activities tied in with their financial status.

Our department allows for UM decisions to be made based only on appropriateness of care and necessity instead of financial rewards or incentives.

Affirmative Statement Regarding Incentives

"In accordance with state and federal regulations, please be aware that all PremierOne Plus MSO physicians' decision-making processes are based upon appropriateness of care and MSO does not provide incentives to encourage denial or approval of patient health care services."

Quality Management

Continously Monitoring Quality of Care and Quality of Service

Our quality management team monitors quality of care and quality of services issues of the client group. PremierOne Plus MSO’s client committee oversees the functions of Utilization Management Department, and takes part in review process to ensure client and contracted providers abide by all NCQA, STATE, DHS, and HEDIS guidelines.

Disclosure of UM Protocols

Effective date: January 2015

Policy:
Upon request of a practitioner, member or the public, the IPA will disclose, policies, procedures and criteria utilized to authorize, modify or deny any healthcare service to practitioners contracted by the group.

Procedure:
1. The group can be called at (714) 495-4392
2. Toll free access is provided through staff that accepts collect calls during regular business hours.
3. Customer service staff will triage specific inbound calls related to UM cases or issues.
4. Customer service staff may handle general inquiries, but members and practitioners must have direct access to UM staff in order to discuss specific UM decisions or processes.
5. Upon request of a practitioner, member or eligible designee, the IPA will provide a paper copy of the criteria utilized in the decision making process related to any requested referral.
6. A disclosure notice will be sent with the written criteria that indicates: "The materials provided to you are guidelines used by this Medical Group to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits available to you under your health plan."
7. The above-mentioned disclosure notice will contain an affirmative statement regarding Utilization Management
incentives.

Distribution of Affimative Statement About Incentives

The organization distributes a statement affirming that UM decision making is based only on appropriateness of care, service, and existence of coverage; the organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service are; financial incentives for UM decision makers do not encourage decisions that result in underutilization.

Affirmative Statement

PremierOne Plus MSO, on behalf of its contracted IPAs and hospital groups, affirms that it encourages appropriate utilization of medically necessary member care and discourages under-utilization of services by the following statements:

• UM decision making is based only on appropriateness of care and services and existence of coverage
• POPMSO does not specifically reward practitioners or other individuals for issuing denials of coverage or service care
• Financial incentives for UM decision makers do not encourage decisions that result in under-utilization
• Providers and practitioners are not prohibited from acting on behalf of the member
• Physicians cannot be penalized in any manner for requesting or authorizing appropriate medical care
• Practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination, promotion or any similar matters.