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your independent health.. choice. <br />NaphCare assigns an authorization number to each off-site occurrence that includes a scenario detailing <br />the approved services integrated with service classes and procedural codes. Only approved services are <br />reimbursed. We review claims to determine that charges are not in excess of the appropriate Usual and <br />Customary Charges. We also review claims for prior payment to prevent duplicate billing. In addition, we <br />review for accuracy to include valid dates of service, CPT and ICD-9 codes, and bundling and unbundling <br />of codes. Any claims that are not valid will be returned to the provider as a denial and a corrected claim <br />will be resubmitted for payment. The following criteria will be used in these reviews: <br />• Eligible Patients <br />• Usual and Customary Charges <br />• Prior Payment <br />• Accuracy <br />Services that support our clients' efforts to stay current and compliant in a dynamic environment <br />include: <br />• Optimize productivity for correctional facilities through automated essential operations <br />• Identify correct payments for providers <br />• Direct contracts with providers <br />• Flexible managed care software that allows for a wide range of date -sensitive fee schedules <br />associated with contracts, including integrated DRG and APC processing <br />• Referral/authorization component to facilitate case management and utilization management <br />• Eligibility, submission/receipt of electronic claim files, and HIPAA standards <br />• Customer service <br />• Facilitate daily transactions <br />• Allow providers to look up a member's eligibility and check claim status <br />• Provide clients a comprehensive, line -by-line bill audit and analysis, ensuring they are charged <br />a reasonable amount forthe appropriate services <br />• Match facility and/or physician bills to itemized statements to identify errors and unbundling <br />of services <br />E. OFF-SITE PREFERRED PROVIDER NETWORK <br />1. NaphCare has recruited and will continue to develop a Preferred Provider Network to provide all <br />covered medical treatment and services that cannot be provided on-site. A complete description of our <br />network for the SAJ is provided within this section. <br />1. We have provided written letters of intent from providers willing to participate in the Preferred <br />Network. We have included letters of intent from the following providers in the Appendix: <br />• Prime Healthcare (includes Garden Grove Hospital Medical Center, Huntington Beach Hospital, <br />and West Anaheim Medical Center) <br />• KPC Healthcare, Inc. <br />• Image Orthopedic Lab, Inc. <br />• New Image Dentistry & Implants <br />• Diagnostic Laboratories and Radiology <br />• BioReference <br />Inmate Medical Services <br />City of Santa Ana <br />25F-81 <br />RFP No. 17-051 <br />82 <br />