Eligibility Verification & Preauthorization

Plastic surgery is authorization-intensive. We handle:

• Preauthorization for reconstructive procedures
• Medical necessity documentation submission
• Photographic evidence uploads (when required)
• Mapping payer policies for cosmetic vs reconstructive indications
• Benefit validation for implants, grafts, and devices
• Confirming global period restrictions

Clinical Documentation Review

• Full review of surgeon’s operative notes
• Verification of flap techniques, graft size, depth, and area
• Alignment with CPT® repair and reconstruction rules
• Ensuring photographic and clinical evidence match payer criteria
• Preventive identification of non-covered cosmetic components

Surgical Coding & Charge Capture

• Multi-layer repair coding (simple, intermediate, complex)
• Size-based measurements for grafts and repairs
• Correct use of add-on codes
• Anatomical specificity for bilateral and multi-region surgeries
• Ensuring compliance with NCCI bundling edits

Claims Submission & Revenue Integrity Checks

• Pre-validation of global surgical package rules
• Device and implant charge capture
• Bundling and unbundling safeguards
• Payer-specific documentation attachment rules applied

Denial Prevention & Management

Plastic surgery denials are common due to medical necessity issues. We aggressively address:

• “Cosmetic procedure” denials
• Missing medical necessity documentation
• Lack of photographic evidence
• Bundling and CCI edits
• Incorrect graft or flap coding
• Modifier-related rejections

AR Calling & Appeals

Our AR team specializes in high-value surgical claims:

• Detailed appeals referencing surgical documentation
• Rebuttal letters mapped to payer-specific reconstructive guidelines
• Implant/device reimbursement follow-up
• Negotiations for underpaid complex surgeries

Secondary billing and coordination of benefits