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MA'SAGED CARE SERVICE SCHEDtiLE <br />Client has chosen the following managed care services, as defined herein: <br />(1) Provider Fee Management -The bill review process reviews bills against up-to-date <br />and accurate mandated state fee schedules or the usual and customary ("UCR") data <br />base, whichever is appropriate, to reveal excessive, duplicate, or inappropriate <br />charges. <br />(2) Preferred Provider Organization ("PPO") Networks - Sedgwick will arrange for <br />access and channeling to national and regional PPO networks including specialty <br />networks (Diagnostics, Physical "Therapy, etc.) under the managed care program in <br />conjunction with the Provider Fee 'Management service. <br />(3) Hospital 13111 Review - Hospital or outpatient non -PPO bills will be reviewed by a <br />nurse for possible errors or excessive charges relative to the patient's medical <br />diagnosis at Sedgwick's or Client's request. <br />(4) Out of Network Bill Review - Bills from out of network health care providers will <br />be reviewed, and if appropriate a negotiation with the billing provider will be <br />pursued. Additionally, inpatient and outpatient procedures that are not addressed by <br />an individual state's fee schedule or 11 -CR will be repriced to a geographically driven <br />and cost to charge repricing database to determine appropriate reimbursement. <br />(5) Specialty Usual and Customary Review — Sedgwick' vendors will apply geographic <br />charges (fee for same procedure charged by other providers in same area) and cost <br />to charge ratios (actual cost to provider for procedure or hospital stay v. amount <br />charged) to determine reimbursement of medical services billed that are not <br />addressed within the jurisdictional fee schedule or usual and customary <br />reimbursement. <br />(6) Field Case Management - Sedgwick will assign appropriate cases for field medical <br />and vocational management services. <br />(7) Utilization Review, which includes the following components: <br />(a) Prospective Review - a review prior to treatment or admission conducted by <br />an experienced registered nurse to validate or negotiate the necessity, setting, <br />frequency, intensity and duration of care delivery. <br />(b) Concurrent Review - during the course of treatment, a review of treatment <br />and planned procedures and establishment of target completion dates. <br />(c) Retrospective Utilization Review- a review post treatment conducted by an <br />experienced registered nurse to identify inappropriate treatment utilization. <br />(d) Peer Review - physician -to -physician contact to resolve treatment and <br />diagnosis questions. <br />C/20912 19 <br />