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Conditional Payment Dispute Resolution <br />Per Inquiry <br />$500.00 <br />Final Settlement Document Submission <br />Per Referral <br />$155.00 <br />Medicare / Medicaid Investigation <br />Per Inquiry <br />$100.00 <br />Medical Cost Projection to MSA Conversion <br />Per Referral <br />$1,200.00 <br />Social Security Investigation <br />Per Inquiry <br />$100.00 <br />Ancillary and Other Managed Care Services <br />Detail Unit Fee <br />All States <br />Diagnostic Network Services N/A Varies by State & <br />Procedure <br />Durable Medical Equipment Network N/A Varies by State & <br />Services Equipment <br />Home Health Network Services N/A Varies by State &Services <br />All States <br />Translation & Transportation Network <br />N/A Varies by State & Services <br />Services <br />Varies by State & <br />Physical Therapy Network Services N/A <br />Procedure <br />IME Network Services N/A I Varies by State & Specialty <br />PPO Network Panels (Required States) N/A No Charge <br />PPO Network Panels (Non -Required States) Per Panel $9.00 <br />Our medical management services include a complete suite of all ancillary medical services, using multiple <br />networks that address our clients' needs — including, but not limited to, pharmacy benefit management, <br />diagnostics, durable medical equipment, transportation and translation, home health, physical therapy and <br />independent medical exams. These services are subject to the bill review rates as quoted above, plus the <br />applicable percentage of network savings achieved below the fee schedule or usual and customary charges. <br />Sedgwick Copyr'ght©2019 The information contained herein is coofidenCial and proprietary to Sedgwick. It is being provided In order to apow <br />evaluationof Sadp .x's servi sand rapahiln'.-. Nothing c, -ned here- should be disclosed to a third party without the prior consent of Sedgwick. <br />