Consulting Services

Consulting Module #10

Quality Review: Appeal Decisions

Who’s checking the checker? Even though your appeal specialists are well-trained, proficient claim professionals, don’t you stand a better chance of achieving sustained excellence with periodic input from outside specialists?

PDA Offering

Armed with years of technical experience and the benefit of extensive industry knowledge, seasoned PDA resources will provide an informed assessment of both ERISA and non-ERISA appeal determinations.

Consulting Module #10

Quality Review: Appeal Decisions


Who’s checking the checker? Even though your appeal specialists are well-trained, proficient claim professionals, don’t you stand a better chance of achieving sustained excellence with periodic input from outside specialists?


PDA Offering

Armed with years of technical experience and the benefit of extensive industry knowledge, seasoned PDA resources will provide an informed assessment of both ERISA and non-ERISA appeal determinations.

Outcomes

Confirms the critical appeals function is being administered consistent with DOL regulations, internal procedures, contract provisions, and industry best practices.

Mitigates the appearance of a conflict of interest, indicating a commitment to a fair process and clear evidence of carrier intent. 

Demonstrates an obligation to making sure claim decisions are made with accuracy and integrity.

Provides appeal managers with an unbiased source of feedback, facilitating a more constructive pathway to employee growth and success.

Outcomes

Confirms the critical appeals function is being administered consistent with DOL regulations, internal procedures, contract provisions, and industry best practices.

Mitigates the appearance of a conflict of interest, indicating a commitment to a fair process and clear evidence of carrier intent. 

Demonstrates an obligation to making sure claim decisions are made with accuracy and integrity.

Provides appeal managers with an unbiased source of feedback, facilitating a more constructive pathway to employee growth and success.

Duration

  • Referral Structure 
  • Decision Adequacy 

Integrate PDA resource into customer’s quality review process

Duration

  • Referral Structure 
  • Decision Adequacy

Integrate PDA resource into customer’s quality review process

For more information contact Mark Sawyer

(207)747-4308

Consulting Modules

#1
STD Claim
Management