Group
Health

Our premier, highly-credentialed PPO network, together with proven pre-certification, utilization management and case management services, delivers high quality, cost-effective care to employer groups. A division of CSG, CHN PPO is a leading preferred provider organization serving the northeastern United States with over 140,000 health care provider locations. A proprietary network with all providers directly contracted, CHN's cornerstone is top-quality health care providers. Widely recognized for our flexibility, responsiveness and quality management practices, our network of medical claims solutions combines quality care with a continuum of medical expense controls. Case by case and bill by bill, we champion our clients' interests to achieve their medical and financial objectives.

Medical Ability

Our highly-trained staff works closely with the provider, patient, and the patient's family to assure that the patient receives the appropriate treatment in the right setting. Our staff includes full time, on-site medical directors, specialty physician advisors, experienced nurse case managers and utilization review pre-certification nurses, each with an average of over 20 years of experience. Our fully accredited CHN PPO network offers full freedom of choice and access in a highly cost-effective manner through physicians and healthcare providers covering a comprehensive range of medical disciplines.

Technical Agility

CSG Services are powered by medlogix® our proprietary, web-based case management software. This seamless, end-to-end technology fully integrates all CSG services into a customizable, user-friendly platform through which all medical case management processes flow in real time. medlogix® expedites efficient communications between the insurer, CSG and medical providers, resulting in highly cost-effective claims handling and medical case management. CSG can customize medlogix® to integrate with claims technology or it can function as a standalone solution.

Available Services

CSG case managers conduct pre-certifications to assess medical necessity and duration of care while ensuring consistency with clinical protocols and the patient's benefit plan. Services may include may include prior authorization, utilization review and case management to determine whether the treatment plan is medically necessary and whether it provides for the appropriate level of care consistent with clinical protocols. Treatment that does not meet this criteria is escalated to a medical director. CSG manages the entire pre-certification process, including appeals and dispute resolution.
Case Managers specialize in managing high-risk, high-dollar claims, including cardiac disease, transplants, high-risk maternity with neonatology, oncology and behavioral health intervention. Effective management of these serious or catastrophic cases can have a significant positive impact on the outcome.

CSG's dedicated telephonic case managers ensure medically appropriate care by assessing medical needs and evaluating treatment options. Treatment management is initiated with triage at the time of injury and continues through all treatment paths. Outcomes are measured by comparing nationally accepted guidelines. Nurse case managers provide constant communication with the adjuster, treating provider, employer and injured worker. CSG physician advisors and nurse case managers gather data, share information and provide ongoing assessments. Their clinical assessment is compared to that of the treating provider and variances are discussed. A proactive course of treatment is mutually agreed upon and an appropriate return-to-work program is implemented through a cooperative team effort.

Case management is directed toward:

  • Early identification and assessment
  • Discharge planning
  • Planning for complications
  • Identifying appropriate physician, facilities and outpatient referrals
  • Avoiding unnecessary hospital admissions
  • Negotiating appropriate rates and levels of care
A Certified Nurse will perform desktop or onsite hospital and provider auditing and review records to ensure all services billed are causally related and properly documented. CSG requests all pertinent information necessary for the review (provider bills, medical authorizations and medical records). Results are documented and recommendations made for payment.

CSG provides a highly advanced bill review system powered by medlogix® -- our proprietary, web-based platform for managing claims information. This seamless, integrated platform provides real-time claims data 24/7 and meets all local, regional and national jurisdiction requirements. Utilizing this powerful system, CSG bill reviewers evaluate the diagnosis relationship, medically necessary treatment and properly coded billing patterns against the corresponding covered loss. medlogix® automatically scans for duplicates and matches treatment codes to actual documented treatment. The bill reviewers utilize this technology to identify improper coding or billed services that may require further scrutiny. Where appropriate, they reprice provider, facility and ancillary service bills. They also apply preferred provider adjustments or, if preferred provider discounts do not apply, refer bills for out-of-network negotiations. The result is the utmost in efficiency and savings for our customers.

medlogix® software employs the following automated analyst edits for all applicable state medical fee schedules and rules, including the following:

  • Current and past state-specific medical fee schedules by regions
  • Applicable PPO fee schedules by region
  • Applicable U&C calculation schedules, where appropriate
  • Multiple procedure reduction formula calculations
  • Modifier calculations
  • Trauma facility flags
  • Policy limit flags
  • Deductible and co-payment calculations
  • Interest calculation
  • Crosswalks (correction of invalid code to a valid code, V-codes, ICD-9, NDC and CPT)
  • NCCI edits
  • Duplicate bill and line checking indicators
A division of CSG, CHN PPO is a leading preferred provider organization serving the northeastern United States with over 140,000 health care provider locations. A proprietary network with all providers directly contracted, CHN's cornerstone is top-quality health care providers. Through these direct network contracts and a national network of PPO affiliates, CHN delivers a coast-to-coast competitive edge to the clients we serve. By partnering with select regional PPOs that meet our rigorous standards for credentialing, accessibility and cost savings, CHN offers seamless national PPO access to our clients.

The direct oversight of a medical professional provides valuable guidance for complex or catastrophic cases, or those that are not progressing as expected. Nationally certified registered nurses (CCM and/or CRRN) with three to five years of catastrophic case management experience assess and coordinate treatment by working with medical care providers, employers, attorneys, injured persons and their families to ensure quality health services are delivered in a cost-effective manner. The result is decreased hardship to individuals and their families/significant others as a result of their injuries and reduced financial exposure for insurers and self-insurers.

Case management is directed toward:

  • Early identification and assessment
  • Discharge planning
  • Planning for complications
  • Identifying appropriate physician, facilities and outpatient referrals, avoiding unnecessary hospital admissions, and negotiating appropriate rates and levels of care
We offer both retrospective and concurrent utilization management services designed to provide high-quality, well-managed care while reducing unnecessary claims costs. Our clinical staff works with the physician to ensure the treatment plans meet the level of care to ensure optimum outcomes. This highly-experienced team, which includes on-site Medical Directors, Specialty Physician Advisors, Nurse Case Managers and Utilization Review nurses, works closely with providers to confirm that treatment plans meet the level of care for optimum outcomes.

Bill negotiations reduce the costs of medical bills from providers and facilities not participating with a provider network for total cost management. The negotiation team proceeds with a review of UCR, Medicare, claims utilization history and in-network payment rates to aggressively negotiate with non-network hospitals, physicians, and ancillary health care providers to reduce costs.

CSG's Bill Negotiation program includes:

  • Direct negotiations by experienced, highly-skilled negotiators with expertise and knowledge of rate levels
  • All negotiations are confirmed with signed Letters of Agreement from providers
  • Average savings of 22-24% below standard bill review reductions
  • High acceptance rate – average of 70%
  • Prospective and retrospective negotiations
  • Customized referral criteria
For cases that require a physician review to determine medical necessity, CSG provides access to highly-credentialed medical directors to provide professional guidance regarding the appropriate treatment of injuries. CSG maintains a full staff of multi-specialty medical directors in all appropriate specialties, which includes numerous medical directors on-site at CSG's customer service center. CSG's technology-enabled medical director review services deliver complete and defensible recommendations. Our robust medlogix® technology distills multi-page medical record documents into one digital file that is easy to access, read and utilize. The result is a more efficient process, increased accuracy, more complete and defensible information, and a more positive interaction with the treating provider.