For Healthcare Providers:

Claims Administration

As a Midlands Choice network provider, you must follow and accept each payer’s administrative and claim policy guidelines, utilization review requirements and claim coding and bundling rules. Claims denied for failure to follow a payer’s administrative or claim policies, utilization review requirements, and claim coding and bundling rules cannot be billed to the patient.

Claims for medical services may only be considered a covered benefit if the care is medically necessary as defined by the payer.

You must provide all information reasonably requested by a payer to enable the payer to make a utilization review determination within reasonable timelines.