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Utilization Review/Certification <br />Detail <br />Unit <br />Fee <br />Ohio <br />Nurse Review <br />Per Review <br />$97.00 <br />Medical Director Review (additional fee <br />when applicable) <br />Per Review <br />$198.00 <br />Medical Director Appeal Reviews <br />Peer Review <br />Detail <br />Per Review <br />Unit <br />$278.00 <br />Fee <br />All States <br />Peer Review <br />Per Hour <br />$195.00 - $400.00 <br />(Depending on Specialty) <br />Physician Intervention Review (Pharmacy <br />Review with Peer to Peer Contact) <br />Per Hour <br />$295.00 <br />Rush Fee <br />Medicare Secondary Payer Services (MSA) <br />Detail <br />Per Rush <br />Unit <br />$100.00 <br />Fee <br />All States <br />Mandatory CMS MMSEA Reporting <br />Per Claim <br />$9.50 <br />Standard MSA <br />Per Referral <br />$2,950.00 <br />Revised MSA <br />Per Referral <br />$500.00 <br />Complex/Catastrophic MSA <br />Per Referral <br />$3,500.00 <br />Rush MSA Additional <br />Per Referral <br />$525.00 <br />MSA CMS Submission <br />Per Referral <br />$525.00 <br />Medical Cost Projections <br />Per Referral <br />$1,750.00 <br />Conditional Payment Request <br />Per Referral <br />$250.00 <br />Sedgwick Copyright ©2019 Thelnformation contained herein i'confidential and proprie[eryto Sedgwk& It is being provide&norderto allow <br />e I-ti.n of Sedgwickssery-and cdpbilHi s. Nothing"r_— h-ld be disclosed to a third party without the prior consent oFSedgwick. k <br />