Comprehensive Reviews. Specialized Expertise. Quality Assurance.
Dane Street is a URAC-certified and NCQA-accredited Independent Review Organization (IRO) that services Health Plans, Pharmacy Benefit Managers (PBM), Third Party Administrators (TPA), Self-Administered Employee Benefits Groups, Utilization Management (UM) Organizations, and Government Agencies nationwide. We can support nurse/pharmacy tech and pharmacist level reviews, generalist and specialty match Prior Authorization reviews, Appeal Review Services, and External Reviews across all lines of business, including Commercial, Pharmacy, Medicaid, Medicare, Duals and Marketplace for Medical, Behavioral Health, and Dental.
In addition to Prior Authorization Medical Director Reviews and Appeal Review Services, Dane Street also supports our clients with Medical Policy Guideline Reviews and Quality Risk Review Services based on the standard of care as well as DRG Validation Reviews and Integrity Dispute Claims Reviews.
Our Health Plan/PBM Physician Panel is composed of over 1,000 board-certified and active-practice physicians across 120 specialties. Our coverage includes top requested specialties such as Hematology, Oncology, Dermatology, Otolaryngology, Cardiology, Psychiatry, and Psychology. We also provide coverage for hard-to-find specialties such as Radiation Oncology, Pediatric Specialists, Genetic Testing specialists, and specialists in ABA Therapy.
Our Quality Assurance Team reviews 100% of all cases before the determination is submitted. Clinical auditing tools are utilized for the assessment of determinations made by our clinical advisors and ongoing training and oversight are provided to ensure the highest quality is maintained.
Our Operations Team is adept at meeting standard, rush, and expedited timeframes. Dane Street provides weekend and holiday coverage. In addition, for many clients, we handle specific UM delegated tasks and partner closely with our clients around Delegation Oversight requirements led by our Regulatory and Compliance Team.
Please see a listing of our service offerings below:
| Health Review Services - Submitted through the client portal or completed in the client system, depending on the scope and size of the project. | |
|---|---|
| Prior Authorization Nurse Level Reviews | Nurse and Pharmacist-level medical necessity determinations for approval of healthcare service, treatment plan, prescription or DME. |
| Prior Authorization Medical Director Reviews | Physician-level review of medical necessity determinations if not approved by the nurse during prior authorization, often performed by a generalist, but can be specialty match if preferred. |
| Peer Review Services - Submitted through the client portal. | |
| Physician Peer Reviews | First or Second Level Appeal same or similar specialty matched physician medical necessity determination after initial review denial. Peer to peer available upon request. |
| Panel Appeal Reviews | Physician Panelists review all submitted documentation for medical necessity determination and join a 30-minute teleconference to discuss the case with the member, treating provider, and attorney if represented prior to issuing a determination. |
| Dental Reviews | Medical necessity determination is conducted by a Dentist, Orthodontist, or Oral Maxillo-facial specialist. |
| Federal & State External Reviews | Final level appeal medical necessity determination requested at the health plan level or by the Department of Insurance conducted by a same or similar match reviewer. Acknowledgement Letters and Determination Letters are issued in accordance with state and federal regulations and timeframes. |
| Quality of Care Reviews | Same or Similar specialty matched physician determinations of whether the quality of the services provided is consistent with professionally recognized standard of care. |
| SIU (Fraud Waste Abuse) | Same or Similar specialty matched physician review of fraudulent, wasteful, or abusive services outside of the acceptable standard of professional conduct of standard of care. |
| Policy Guideline Reviews | Evaluation and review of current peer-reviewed literature and evidence-based medicine for suggested updates or changes to the health plan’s medical policy regarding a treatment or service for all applicable diagnoses. |
| Payment / Coding Review - Submitted through the client portal. | |
| Payment Integrity Disputes | Review of claims payment against medical records to ensure payment accuracy. |
| DRG Validation Reviews (Inpatient) | Verify proper coding of all diagnoses and procedure codes and accurate and complete recording of all data elements that affect the DRG assignment of documentation in the medical record. |
Whether you are a physician exploring new opportunities, a claims adjuster looking for the responsive claims support they need, a job seeker looking to discover a growing, award-winning company to build a career with, or if you're simply curious about what we do, we'd love to tell you more — just click below!
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