Claims Development Management Earns Fourth NCQA UM Accreditation

Claims Development Management (CDM), a healthcare utilization management organization, established in 2013 and accredited in 2015 to deliver oversight to its clients under the National Committee for Quality Assurance (NCQA) https://www.ncqa.org guidelines, has earned its fourth Accreditation this May 3, 2022. This Recognition exemplifies CDM’s commitment to compliance and excellence in promoting high quality, well-coordinated, appropriate, and cost-effective care to members of its contracted health plans while honoring NCQA’s standards of excellence on continuous quality improvement, utilization management, and ongoing quality programs for all health plan partners.

CDM’s Utilization Management Accredited program focuses on a Quality Program of Preservice and Retrospective review. The purpose of the program is to provide the framework for the evaluation of processes and outcomes related to member care and organizational functions. This is accomplished by assessing medical necessity and promoting quality appropriate medical intervention. All activities of the UM Program are coordinated in collaboration with our contracted health plans and are in accordance with regulatory agencies. This is achieved by the integration of utilization review, risk management, and quality assurance into utilization management to ensure the judicious use of the entity’s resources and high-quality care.

CDM’s most recent and fourth NCQA UM Program Accreditation solidifies its commitment and dedication to the service level it delivers to its partners. One of those highlighted partnerships is with Provider Network Solutions (PNS), a Value-Based Specialty organization. PNS is a market leader and innovator that partners with a Third-Party Administrator; aligns Health Plans, Primary Care Physicians, and Specialists; and manages governmental and commercial lines of business. PNS and CDM collaborate on the utilization management functions of PNS’s networks of over 2,400 providers facilitating the delivery of health care services to approximately 3,200,000 members.

“As a partner of Claims Development Management, we stand to gain from this notable NCQA’s Accreditation, since we work together to ensure that our member’s care is appropriate, cost-effective, and of high quality under the NCQA Accredited guidelines,” said Dr. Thao Tran, PNS Chief Medical and Quality Officer, “the responsibility of quality care benefits our providers and all patients involved,” Dr. Tran added.

Claims Development Management

Claims Development Management (CDM) was established in 2013 to ensure utilization management decision-making through a variety of specialty networks. CDM’s team issues authorizations for medically necessary and covered health care specialty services and/or makes recommendations to the health plan for denial of care based on lack of medical necessity after application of criteria. CDM also conducts retrospective review to ensure the clinical care is according to medical standards. The overarching operation of CDM shares the values and mission of the http://ncqa.org and the Institute of Healthcare Improvement (IHI) http://ihi.org framework to enhance the patient experience, better the health of the population and reduce healthcare costs.

Providers Network Solutions

Provider Network Solutions (PNS) was established in Florida in 1998, it serves as a prominent Value-Based Specialty organization, connecting payors with over 2,400 Specialty Medical Providers in Dermatology, Podiatry, Orthopedics, and Pain Management. PNS is focused on providing member access and improving clinical outcomes through advanced analytics, specialty risk management expertise, and compliance with accreditation standards and information systems security guidelines. PNS is profoundly focused on providing member access and improving clinical outcomes by aligning to the adherence of regulatory requirements – yielding over 97% of Provider and Health Plan retention over its 24 years in business.

National Committee for Quality Assurance (NCQA)

NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. NCQA’s website (ncqa.org) contains information to help consumers, employers and others make more-informed health care choices. NCQA can be found online at ncqa.org, on Twitter @ncqa, on Facebook at facebook.com/NCQA.org/ and on LinkedIn at linkedin.com/company/ncqa.

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