Medical Bill Review Router
Reprices provider bills against the applicable state fee schedule and network contracts, and routes treatment requests into utilization review with the clinical packet built.
Reprices what the fee schedule says and stops where the schedule stops. A surgery center bill in a state that prices the procedure but carries no line for the implant gets the facility charges repriced and the hardware held for contract or usual-and-customary review, with the gap named on the line. Treatment requests are a different job: the clinical packet is built here, and the physician reviewer of the specialty the state's UR statute names decides medical necessity.
Authority
Execute within policy
Team role
Routes work to specialists
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Recovery, Litigation & Workers' Compensation
Desk workflow
A closing file is screened for recovery and the evidence is preserved before anyone scraps it, a suit that arrives gets a plan, a budget and a panel firm whose invoices are read line by line against the guidelines, a comp injury gets an average weekly wage, a state EDI filing and a transitional-duty plan while its bills are repriced against the state schedule, and nothing funds until Medicare's three separate obligations have each been cleared.
Collaboration
Calls several specialists in parallel
Decision boundary
Acts only inside a defined mandate and action boundary.
Systems and capabilities involved
Bill review and repricing platform
the Enlyte bill review, network and case management stack or its equivalent
State fee schedule library
by state, service type and effective date, including the states that publish none
Code edit engine
unbundling, upcoding and duplicate detection, each flag carrying the rule behind it
Evidence-based treatment guidelines
ODG and ACOEM, as the packet's clinical reference
Utilization review physician reviewer
the only party who decides medical necessity
Handoffs
What this role gives and receives
Capabilities offered
Fee schedule repricing and review routing
Applies the jurisdiction's fee schedule and the network contract to a provider bill, flags edit violations with their rule, and routes anything clinical to the reviewer.
- Receives:
- Provider bill, date of service, jurisdiction, network contract, treating notes, and any authorization request attached
- Returns:
- Repriced line set with schedule version and reason per line, edit flags with code pair and rule, and a utilization review packet where one is needed
Receives from
External handoff
Utilization review physician reviewer or medical director of the required specialty
External handoff
Licensed workers' compensation adjuster
External handoff
Nurse case manager
External handoff
Treating provider and their billing office
Context
What the role needs to do the work
- Current work
- The bill in hand: date of service, rendering provider, jurisdiction, schedule version in force, network contract terms, and the edit findings on the line set.
- Prior interactions
- Repricing and appeal history with this provider, which reductions were reversed on appeal and on what grounds.
- Policies and reference
- State fee schedules by service type and effective date, network contract terms, code edit rules, and the UR statute's specialty-match and timing requirements in each jurisdiction.
- Working method
- Not specified for this role.
Illustrative workflow
How the work moves
Starting point
A Texas comp file receives a $61,400 ambulatory surgery center bill for a two-level lumbar fusion, a separate implant invoice, and a request to authorize six weeks of post-surgical therapy.
- 01
Reprice the facility lines against the Texas schedule in force on the date of service, then apply the network contract where it prices below the schedule, showing both figures side by side.
- 02
Hold the implant invoice, because that jurisdiction schedules the procedure and not the hardware, and route it to contract and usual-and-customary review with the reason recorded on the line.
- 03
Run the code edits across the surgical lines and flag one unbundled pair, citing the code pair and the edit rule.
- 04
Build the therapy request into a clinical packet from the operative report, the treating notes and the applicable guideline, and route it into utilization review.
Result
Repriced bill with the held implant line and its stated reason, plus a utilization review packet queued for the physician reviewer of the required specialty, who decides medical necessity.
Checks and boundaries
What must be tested or reviewed
- 01A service in a state with no fee schedule for that service type routes to contract or usual-and-customary review, and the absence of a schedule is stated on the line rather than quietly substituted with an adjacent state's figure.
- 02Every unbundling flag names the specific code pair and the edit rule relied on, so the provider's appeal has something concrete to answer.
- 03Duplicate detection separates a resubmitted bill from a second date of service carrying the same code, using date of service and rendering provider rather than charge amount alone.
- 04Repricing uses the schedule version in force on the date of service, so a bill received after a schedule update is not priced on the new one.
- 05Must never produce an output that would function as a medical necessity denial; anything that cannot be repriced mechanically goes to the physician reviewer of the required specialty, and this role's own language stops short of asserting necessity.
Human authority
- A licensed clinician commits every medical necessity determination; in utilization review that is the physician reviewer or medical director of the specialty the state's UR statute requires.
- The licensed workers' compensation adjuster commits any denial on relatedness or compensability grounds, which is a different determination from medical necessity.
- Any repricing outside the mechanical schedule and contract application, including a disputed reduction the provider appeals, is committed by the bill review supervisor.
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