What geographical areas does the MedCost network cover? How do I verify whether a provider is in the MedCost network? If a practice is listed in the MedCost Provider Directory or on the MedCost Web site are all of the providers in the practice in-network? How can I get directories? Why do claims come to MedCost? Is a MedCost patient entitled to receive the MedCost discount for non-covered services? What clinical criteria do you use to make certification decisions? Does certification mean that the claim for the requested service will be paid? What is my recourse for noncertification? Who makes “medical necessity” decisions? What are your physician consultant credentials? What is case management? What credentials does MedCost health management have? Is MedCost HIPAA compliant?
MedCost’s network of providers is located primarily in North and South Carolina.
How do I verify whether a provider is in the MedCost network?
While you’re on our Web site you can easily search our online directory of in-network providers. This provider database is updated monthly. Click here to access our online provider directory. You can also verify participation by calling MedCost’s Customer Service Contact Center at 800-824-7406.
If a practice is listed in the MedCost Provider Directory or on the MedCost Web site are all of the providers in the practice in-network?
Although a practice is listed as a participating provider, not every physician in that practice may be considered a participating MedCost Preferred provider. When scheduling an appointment at a physician’s office, hospital, or facility, it is important to verify that the provider you wish to see is currently participating in the MedCost Preferred network. You can verify a provider’s participation by calling MedCost’s Customer Service Contact Center at 800-824-7406.
How can I get directories? Directories for employers are free up to 150% of the total employee count based on the renewal date. Email your request for directories to Michelle Shoaf at mshoaf@medcost.com
Please include:
Contact name
Company name
Street address and zip code
Telephone number
Number of directories requested, and for which state
Why do claims come to MedCost? MedCost negotiates with selected physicians, hospitals, and facilities to arrange reduced fees for a broad range of medical services. MedCost receives claims from our network providers, reprices the claims to these lower negotiated rates, then forwards the claims to the claim administrator for payment.
Is a MedCost patient entitled to receive the MedCost discount for non-covered services? Participating providers agree to accept the MedCost allowable amount for non-covered services.
What clinical criteria do you use to make certification decisions? Milliman Care Guidelines are used to facilitate the certification decision. The guidelines are evidence based. Developed by physicians, nurses, and other health care professionals based on the actual practices of clinical care providers throughout the United States and the most current medical literature, the Milliman Care Guidelines outline the most efficient treatment for a given condition and the typical progress that patients can expect. Sources of information for Milliman Care Guidelines include medical literature, textbooks, and nationally recognized guidelines published in all fields of medicine, practice observations, and database analyses.
In weighing and grading the evidence, Milliman USA uses the following hierarchy of evidence, with the first level being the most important:
• Evidence Grade 1: Randomized controlled trials
• Evidence Grade 2: Nonrandomized published research
• Evidence Grade 3: Unpublished research:
• Large databases
• Quality improvement projects
• Expert practitioner reports
Does certification mean that the claim for the requested service will be paid? Certification is not a guarantee of payment. The certification process confirms the medical necessity of the service. It does not confirm the member eligibility or coverage for the service. All questions of eligibility for a specific patient and coverage for the requested service should be confirmed by contacting the claim administrator.
What is my recourse for noncertification? An appeals process is available when a service has been noncertified for a medical necessity reason. Please contact the precertification number listed on the insurance card to initiate this process or follow the instructions on your certification notice. You are encouraged to send complete information and medical records regarding the non-certified period. All information received will be reviewed and a determination will be made. A written notification of the decision will be sent to the patient, providers, and claim administrator.
Who makes “medical necessity” decisions? At MedCost, registered nurses collect medical information and review it against Milliman Care Guidelines. If there is any question of medical necessity, the medical information is reviewed by a physician. MedCost has a panel of over 90 consulting physicians. All physicians are board certified in various specialties and are in active practice.
What are your physician consultant credentials? All MedCost consulting physicians are board certified in their various specialties and are in active practice.
What is case management? Case management is a program that allows for early intervention and management of cases involving serious or catastrophic injuries or illnesses. Case managers are registered nurses who work with the patient, the providers, and the claim administrator to ensure that the patient is receiving the right level of care at the right time. Case managers help to make the most efficient use of health plan benefits over the course of long-term treatment.
What credentials does MedCost health management have? MedCost health management programs are accredited by URAC. MedCost is also accredited under URAC provider credentialing standards.
Is MedCost HIPAA compliant? MedCost is fully compliant with all of the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to date.
Updated January 19, 2009