Clinical Review of Denied Eligibility Cases

This is an AArete Healthcare Payer Insight


The Division of Developmentally Disabled (DDD) state agency had fallen behind required responsiveness for clinical review of denied eligibility cases in appeal. DDD had experienced negative publicity and court filings due to lack of timely reviews and responses to members seeking DDD services.


AArete assembled a team of 14+ doctors with necessary credentials, created a process for HIPPAA secured file transfer, doctor review and documentation, provided expert witness testimony in support of clinical opinions in court cases and provided data metrics and analysis on various problems.


AArete performed several hundred case reviews, multiple expert witness testimony in cases going before the court and provided data metrics/analysis on various roadblocks within the process allowing DDD time to create a department better able to handle the complexity and volume of ongoing appealed eligibility reviews.