2022/08/31 Council Agenda Packet

SCHEDULE 3-A Clinical and Technical Assessment Services Terms and Conditions 1. DESCRIPTION OF SERVICES (a) Clinical and Technical Assessment Services. CorVel provides this service to evaluate state specific complex rules and verify coding by providers when appropriate and supported by documentation. This can include clinical review to validate coding is correct for all applicable Provider bills, Ambulatory Surgical Center bills, and all Hospital bills (inpatient and outpatient) including: (i) review and analysis of codes, charges, and billing structure for incorrect coding, incorrect billing, bundling, and up -coding of procedures which affect Standard Fee Schedule values; (ii) review of bills, records, and documentation by a nurse and/or by a coder; (iii) separation of charges not related to the compensable injury; (iv) review and apply complex state specific rules; (v) application of utilization review determinations and clinical edits; (vi) diagnostic related group validation (i.e., verification that the diagnostic related group billed is appropriate for the services rendered); and (vii) cost shifting of revenue and CPT codes. 2. DELIVERY OF SERVICES (a) CorVel will timely and within industry standards, complete Review Services and return the reviewed Bills to Customer, with any adjustments to identified overcharges. (b) Savings for the Review Services shall be: (i) for states having a state mandated Standard Fee Schedule: (A) the bill amount in the Fee Schedule; less (B) the bill amount resulting from the nurse review services. (ii) for states not having a state mandated Standard Fee Schedule: (A) the medical provider's original bill amount; less (B) the bill amount resulting from the nurse review services. (iii) for states having a state mandated Standard Fee schedule (A) the medical provider's original bill amount; less (B) the bill amount resulting from technical review services. (iv) for states not having a state mandated Standard Fee Schedule: (A) the medical provider's original bill amount; less (B) the bill amount resulting from the technical review services. (c) Customer Responsibilities (i) Customer shall pay bills reviewed by CorVel in a timely manner in accordance with all state guidelines, and agrees to waive any bill audit and/or other retrospective reviews regarding all bills for which CorVel has secured a reduction from the original billed charges. (ii) If a medical provider submits an appeal, the bill will be reviewed again and, if any adjustment City of Everett, WA — CorVel EC Amendment 3 7-25-2022