1. R.A.C. (Random Audit Contractor)
 This is the review system initiated in 2010 to cut short the cost and prevent adulteries
in health claims. Contractors can review any claim from 2007 till date. If any
overpayment is observed contractor can issue demand notice for recoupment of
overpaid amount.
 Hospital are given right to appeal against the decision of RAC.
 The appeals are processed in five levels. i.e.
1. LEVEL I : Fiscal Intermediary
2. LEVEL II : Quality Independent Contractor
3. LEVEL III : Administrative Law Judge
4. LEVEL IV : Appeals Council Review
5. LEVEL V : Judicial review in US district Court
 Our team experienced in writing up to level III appeals.
 These appeals are mainly concentrated about physician admit order and medical
necessity for inpatient admission and support the same with severity of illness and
intensity of services provided to the patient.
 We also use updated industry standard Admit criteria like Milliman Care Guidelines
and InterQual Criteria for inpatient admission
M.A.C. (Medicare Administrative Contractor)
 These contractors take care of CMS administrative work under Section 911 of the
Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003.
 MAC will process the claims and pay them according to guidelines of CMS.
 MAC can deny claims which are not meeting CMS guidelines.
 We write appeals for MAC mainly concentrating on expected length of stay of the
patient as CMS guidelines say expected hospital stay for more than 24 hours or two
midnights is mandatory for claim payment.
 We also use updated industry standard Admit criteria like Milliman Care Guidelines
and InterQual Criteria for inpatient admission
Commercial Appeals
 These are the appeals we write for insurance companies other than CMS.
 Every insurance company has its own payment and coverage guidelines.
 The format we follow it is prepared thoughtfully that it can be used for all payers with
minimal interference in the structure of appeal letter.
 In these appeals severity of illness and intensity of services provided for the patient
are mainly projected so that the claim must be paid properly.
 Using Admit criteria like Milliman Care Guidelines and InterQual Criteria for
inpatient admission will add value to appeals.

2. A.C.F. (Admit criteria Forms)
 These are the market standard guidelines for admission of patients in hospital which
are helpful for hospitals to support admission of patient while dealing with denials
from payers.
 Inclusion of ACFs in medical records will add extra value for prevention of denial of
claims.
 Our clinical managers are expert in MILLIMAN GUIDELINES and INTERQUAL
ADMISSION CRITERIA, the two very frequently used and most popular guideline
on market.
 We also keep ourselves updated with new versions of above said guidelines every
year and adapt to them at earliest to provide the hospital with updated information.
Inpatient Service Codes Denials
 During review, insurance company or contractor may deny/change one or more
primary/secondary diagnosis codes used in billing which intern changes the DRG and
value of claim amount.
 We support the billing of denied code/codes using industry standard coding clinics
and coding guidelines.
Outpatient Service Codes Denials
 Similar to above service code/codes used in billing can be denied in outpatient claims.
 We use LCD (Local Coverage Determinations) and NCD (National Coverage
Determinations) in appeals for these type of denials.