If you are a claim administrator interested in utilizing the MedCost PPO network or Health Management Programs, please contact Cindy Hughes in the marketing department for more information. You can reach Cindy by phone (336-774-4375) or email (chughes@medcost.com).

MedCost’s network of providers is located primarily in North and South Carolina.

Claim administrators may request 200 free directories. Directories for employers are free up to 150% of the total employee count on an annual basis. Email your request for directories to Michelle Shoaf at mshoaf@medcost.com. Please include:
Contact name
Company name/claims administrators name
Street address and zip code
Telephone number
Number of directories requested, and for which state

Please notify MedCost by completing a New Client Form and submitting it to MedCost. You can download this form by clicking here.

Address changes should be submitted by email to clientservices@medcost.com.

Please notify MedCost of employer group terminations by completing a Termination Form. You can download the form by clicking here. Instructions for submission are on the form.

If a request to add or terminate a client is received 30 or more days after the requested effective or termination date, it is considered late. For incomplete forms, the date of receipt is the date that MedCost is provided with all the information necessary to process the request.

Companies are added to the MedCost system but not assigned an effective date when:

• An ID card is not provided to MedCost with the New Client Form.
• An ID card is provided that does not meet our criteria.
• A New Client Form has not been received from the claim administrator.
• Benefit plan information is not fully completed on the New Client Form.
  

The cost to savings ratio is your savings divided by the administration fees paid. This number is the total dollars saved for every dollar spent for PPO access.

MedCost medical management programs are accredited by URAC. MedCost is also accredited under URAC provider credentialing standards.

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

An appeals process is available when a service has been noncertified for a medical necessity reason. Please contact the pre-certification 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 noncertified 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.

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.

All MedCost consulting physicians are board certified in their various specialties and are in active practice.

MedCost is fully compliant with all of the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to date.

Most participating providers agree to accept the MedCost allowable for non-covered services.

While our current system is set up to handle a multitude of contract types, our repricing will only be shown as one total and not by detail line.

MedCost does not have an online coding software product. If your organization wishes to implement coding software, please contact your marketing representative.

MedCost’s success in the PPO market has, in part, been related to our ability to customize fee schedules based on the needs of a geographic area. Additionally, we administer repricing policies consistent with CPT guidelines, and most of this is not an automated process. Because we are good at what we do, and we are also able to provide good data. As the sole owner of the input of this data, we have maintained that the traditional PPO relationship that MedCost has maintained since its inception is the best business practice for our continued success. Additionally, with the increase of EDI volume to MedCost through the traditional PPO claims filing methodologies, we can now offer an outbound EDI repricing product that is more beneficial than in-house repricing.

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MedCost routes repriced physician and facility claims via a clearinghouse. For more information, please contact Suzanne Young, ext 4178, syoung@medcost.com.