Business ProfileforPrairie States Enterprises, Inc.

Both of the members issues are related to a dependent.

#1: PSE received a request for surgery, which was approved as medically necessary. Once the claims arrived to ***, were sent to network for reprocessing. This is so the claim can be reviewed and edited for appropriate amounts to be paid. For the service that was in Feb of 2023, the claim was not received from the surgery center until mid-August 2023 and was paid in mid-October. Upon review of the claim via the Pluto edit system (not PSE) they determined the billing of the surgeon and the facility did not match, were not appropriate, and edited the claim. The claim document sent to the member showing what was paid and not paid, explained to call ***** at ************, so they could direct them on any next steps and explain the situation.
At this time, the facility has recently sent in a corrected claim which is currently being reviewed by the network for appropriate discounts to be rendered.

#2: On the recent denial of a procedure, PSE received a request for surgery on 12/11/2023.The ** RN was not able to approve the request and sent the item to specialty medical review. Once sent, the ** RN also sent a letter to the ordering provider letting them know that an MD was reviewing the request and a peer to peer  ( Physician to Physician) call *** occur in the next few days. We also share the number listed in case they want a different number added to the peer to peer. During the review,the MD called for peer to peer on 12/13/2023 at 10:12 am CT, 12/13/2023 12:35 pm ** and on 12/18/2023 2:34 pm **. As no peer to peer call was returned within the timeframe of review, the MD reviewer was able to review the medical plan document and clinical information only. The result of this information was a denial as not medically necessary. This denial result was issued via a letter to the member and provider, including appeal rights, on 12/19/2023. The provider then called on 01/02/2024, about making a peer-to-peer call. At that time, since the denial was rendered, PSE advised that the time for a peer-to-peer has passed, and the decision is complete. The member and provider have a right to appeal, and we allow peer to peer conversations during the appeal review as well.  

However,to rectify this situation, upon my direction, Prairie States will make an exception to the process and reopen and extend the peer-to-peer period.  We have the majority of the data to complete this process expeditiously and shall do so. 

Both of the members issues are related to a dependent

#1: PSE received a request for surgery, which was approved as medically necessary. Once the claims arrived to ***, were sent to network for reprocessing. This is so the claim can be reviewed and edited for appropriate amounts to be paid. For the service that was in Feb of 2023, the claim was not received from the surgery center until mid-August 2023 and was paid in mid-October. Upon review of the claim via the Pluto edit system (not PSE) they determined the billing of the surgeon and the facility did not match, were not appropriate, and edited the claim. The claim document sent to the member showing what was paid and not paid, explained to call Pluto at ************, so they could direct them on any next steps and explain the situation.
At this time, the facility has recently sent in a corrected claim which is currently being reviewed by the network for appropriate discounts to be rendered.

#2: On the recent denial of a procedure, PSE received a request for surgery on 12/11/2023. The ** RN was not able to approve the request and sent the item to specialty medical review. Once sent, the ** RN also sent a letter to the ordering provider letting them know that an MD was reviewing the request and a peer to peer  ( Physician to Physician) call *** occur in the next few days. We also share the number listed in case they want a different number added to the peer to peer. During the review, the MD called for peer to peer on 12/13/2023 at 10:12 am CT, 12/13/2023 12:35 pm ** and on 12/18/2023 2:34 pm **. As no peer to peer call was returned within the timeframe of review, the MD reviewer was able to review the medical plan document and clinical information only. The result of this information was a denial as not medically necessary. This denial result was issued via a letter to the member and provider, including appeal rights, on 12/19/2023. The provider then called on 01/02/2024, about making a peer-to-peer call. At that time, since the denial was rendered, PSE advised that the time for a peer-to-peer has passed, and the decision is complete. The member and provider have a right to appeal, and we allow peer to peer conversations during the appeal review as well.  
However, to rectify this situation, upon my direction, Prairie States will make an exception to the process and reopen and extend the peer-to-peer period.  We have the majority of the data to complete this process expeditiously and shall do so.