Triad Healthcare Inc. Provider Website

Our Process

Triad Healthcare, Inc. offers a set of services, which work together to provide the best in pain care management. The core of Triad's program is our Utilization Management Process and Medical Policy Development. Triad's pain management solutions are tailored to meet the client's expressed needs for improved outcomes and service preferences.


Care Management

All managed care organizations strive to deliver quality healthcare while controlling costs. In this sense, Triad Healthcare, Inc. is no different than many others. Often, however, it is the cost that is used to determine the value of the program and quality health care delivery can suffer. Quality measures are often created after cost measures are ensured, resulting in "quality" that can be as much "rationalization" as it is "reality." Rationalized quality may offer a pleasing, annual, bottom line, but real quality offers this with the additional benefit of member satisfaction. Satisfied members and their employers offers the opportunity for many pleasant annual bottom lines. Our Care Management programs are focused around member and employer satisfaction. We place a legitimate emphasis on education across those stakeholders who are important to our clients: the patient, the employer and the provider.

Prospective, Retrospective and Concurrent Review
Healthcare providers determine what medical services are rendered and why. This role should not be controlled by the development of policies and rules that do not allow adequate latitude to provide the best care for the patient. Our position is that it is best to manage care by managing the provider and not profession. To do this, we manage each member's care with the treating provider, individually.

Triad Healthcare, Inc. offers a full range of operational services that support its unique medical management philosophy. We manage cases based on clinical necessity following specific criteria which includes:

  • Nature, severity and complexity of complaints
  • Duration of symptoms
  • Numerical Pain Rating Scale
  • A Proprietary Severity Matrix and Functional Index
  • Collection of clinical data thru initial and continuing care forms for both in and out of network provider services
  • Establish, maintain and apply medical necessity criteria as a basis for evaluating care
  • Automation of authorizations
  • Outcomes and quality review

Certification and extension of patient care is based on clinical necessity, objective documentation of recovery and patient outcomes

Member and Provider Education
Triad Healthcare, Inc. is dedicated to providing high-quality, cost-effective customer service to meet the needs of patients, plan sponsors and providers. Training of all Customer Service representatives is conducted on an on-going basis. Member and provider services can be tailored to fit with the health plan's philosophy concerning the optimal level of interaction between its members and its "carve-out" vendors. Triad Healthcare, Inc. representatives educate members and providers about specialty care and address any questions and concerns. Our call center uses on-line inquiry systems, imaging technology and a contact management system to support both members and providers.

These services include:

  • Toll-free call center services for Member and Provider inquiries
  • Referrals to network provider.
  • Member appeal initiation, tracking and resolution
  • Member benefit and plan eligibility verification
  • Member communication regarding UM and appeal issues-telephonic and written
  • Provider communication of UM decision explanations - telephonic and written
  • A program designed to allow patients to discuss their care with Triad Healthcare, Inc. Physicians when a determination of current course of care may not appear to be medically necessary.
  • Annual member satisfaction survey

Broker and Customer Education
Triad Healthcare, Inc. representatives educate providers and members about the program, assist providers and members with claims status and utilization management inquiries, resolve problems, and initiate appeals where appropriate. Our account managers serve as primary point of contact to client organizations and plan sponsors. The level of interaction that our customer service has with client plan participants or members varies based on the health plan's customer service philosophy concerning "carve- out" vendors. We work with each carrier to optimize the level of service to providers and members to make sure it is cost-effective for both organizations and clear to the member.

Medical Policy Development
Triad Healthcare, Inc. has created a comprehensive medical policy development program intended to optimize the relationship between the vendor, client and provider.

We have accomplished this through:

  • Professional, Consensus Driven Policy Development (QIC)
  • Real-time data feeds
  • class="bullet-li"Employing Practicing Providers - all providers employed by Triad Healthcare, Inc. are required to practice a minimum of 20 hours per week in the field
  • Literature Review
  • URAC Accreditation

Cost Management

Triad Healthcare, Inc. sees cost management as a business function unrelated to care management. We develop and guarantee annual costs based on the analysis and expectation of our Care Management programs. Cost Management programs focus on the business functions and the accuracy of those functions.

Our company will analyze your data to determine the cost and delivery of medically necessary specialty care. If the cost is less than what you are currently spending, then we are the company for you.

Claims Processing and Payment
Triad Healthcare, Inc. has designed a proprietary system to execute payment based on medical necessity. This software program allows customization according to client specifications. Claims are processed and paid based on client plan designs, eligibility parameters and Triad Healthcare, Inc. medical management criteria. We accept both electronic (837 HIPAA standard) and paper claims and use a number of coordinated software programs, imaging systems and technologies to review, edit and pay claims within required timeframes. Claims processing includes:

  • Direct receipt and processing of providers' electronic and paper claims
  • Receipt and processing of provider claim files from the insurer
  • Monitoring of turnaround time requirements for processing "clean" claims
  • Issuance of provider checks, remittance advices and denials
  • Creation and customization of Member EOBs
  • Claims analysis and reporting

Fee Schedule Development
Triad Healthcare on an annual basis analyzes fee schedules for our participating disciplines by professional survey, industry sources, trending and our own proprietary utilization data to create fee schedules specific to our provider network and our clients' needs. These schedules ensure that fees paid for medically necessary services are appropriate for the value derived in a market and region specific basis. Triad negotiates and provides consensus for all fee schedules with our provider population by employing a number of methodologies including committee review and focus groups. Triad also surveys competitive fee schedules in the markets in which we operate to ensure that our fee schedules are either competitive or provide an advantage to us and our clients in the context of cost management.

Provider Contracting
Triad Healthcare, Inc. offers a national network of over 7,000 Allied health providers. We can combine our client's existing network with our own, and have been successful in the delegation of credentialing from our clients.

We recruit providers based on parameters mutually agreed upon with the client. In the event that Credentialing is not delegated by the client, we have developed successful programs to provide the client with all the benefits of a delegated credentialing program without the need for annual audit or accreditation organization concerns.

Triad Healthcare, Inc. will manage the quality of the provider network through a combination of continued re-credentialing, provider surveys, focus groups, provider profiling and provider education programs. Network Management services include:

  • Provider recruitment
  • Fee schedule development and maintenance
  • Primary-source verification and credentialing support
  • Provider education and training on client policies and plans
  • Preparation of provider profiles on service and utilization patterns relative to benchmarks

Risk Management
Annually, Triad Healthcare, Inc. develops clinical and business models for expected future utilization. These models allow us to work with our clients to prepare for probable changes in member and provider behavior. To date, our predictive modeling programs have yielded an aggregate accuracy of greater than 90%. These models also allow us to share and/or fully assume its client's claims risks. We maintain cash reserve to assure that any fluctuation in projected cost trends can be tolerated without impacting our client relationships or quality of service.

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