Group Health

Dane Street provides medical peer reviews that assist the Utilization Management (UM) process for many leading health insurance providers in accordance with NCQA standards.In addition, we also provide independent review programs for state and local government entities that address medical necessity, quality of care, and other clinical criteria. Our independent review services comply with all requirements for performing reviews associated with the Patient Protection and Affordable Care Act (PPACA) and HIPAA, as well as best practices around the handling of PHI.

Listed below is a summary of the type of work we currently manage for our clients:

Referral Types: Pre-Service, Post-Service, Pharmacy, First Level Reviews and Appeal Reviews across various Lines of Business:

  • Commercial
  • Government Program Divisions (Medicare & Medicaid)
  • Behavioral Health
  • Clinical Risk (Fraud & Abuse and Special Investigations)

We also handle a variety of non-medical necessity reviews, including:

  • Standards of care
  • Opinions regarding Medical Policy Language

Our physicians are part of a boutique panel of over 2,300 board-certified specialists, covering specialties such as pharmacy, dental, optometry, ophthalmology, chiropractic, and podiatry, and well as hard-to-find specialties such as radiation oncology, child psychology, addictive medicine, and autism specialists.

Our Quality Assurance Clinical team reviews 100% of cases prior to client delivery, and our Operations team is adept at handling standard, rush and expedited cases. Inter-rater Reliability tools are utilized for the assessment of decisions made by all clinical advisors and training is provided where there is identification of a potential need for improvement. In addition, for many clients, we handle specific UM delegated tasks such as the provision of Member Friendly rationales.

Dane Street partners with our clients closely around Annual Delegation Audits (led by our Regulatory and Compliance team) and delivers detailed monthly outcome reports as well as results from Monthly and Quarterly case audits, which are configurable by client.