Utilization Management
Innovista’s utilization management (UM), compliance, and referral coordination teams work together closely to support providers in delivering clinically necessary and effective care with minimal administrative burden.
- Assess patients’ clinical presentation and determine appropriateness of referral requests
- Use evidence-based criteria to ensure patients are managed at the appropriate level of care
- Review the members’ scope of benefits and confirm eligibility
- Ensure UM Plan, National Committee for Quality Assurance (NCQA), and Centers for Medicare & Medicaid Services (CMS) requirements are met
- Conduct external health plan audits
- Collaborate with providers, facilities, and care management teams to ensure safe patient discharge
Claims Management
Innovista has a skilled claims management team that ensures claims are processed properly, ultimately saving operational costs due to efficiency. Services include:
- Reviewing and auditing all claims
- Claims adjudication
- Ensuring all provider demographic information, contracts, fee schedules, and codes are entered into Innovista’s systems accurately
- Checking for billing errors
- Coordinating subrogation
Customer Service
Innovista has a full-service customer service team that supports all provider and member inquiries during the weekday, with an after-hours hours answering service for evenings, weekends, and holidays. The team is staffed with bilingual representatives for our Spanish-speaking members and has a language interpreting service line to support all other languages.
Innovista consistently exceeds the requirements set forth in the Medicare Advantage Communications and Marketing Guidelines, which mandate a rate of greater than 80% of calls answered within 30 seconds, and less than 5% abandon rate for calls.
The team assists in a wide range of member/provider inquiries, including eligibility and referral status verification, claim status, and benefit inquiries.
