Permedion
Permedion is a wholly owned subsidiary of Gainwell.
Permedion provides utilization management services to help safeguard against unnecessary or inappropriate use of services and against excess payments. Services include prior authorization, prepayment and post-payment clinical reviews to help ensure that inpatient and outpatient services are medically necessary, occur in the appropriate setting, are billed appropriately and are of the highest quality.
We also provide Independent Review Organization services for state Departments of Insurance and other entities under the Patient Protection and Affordable Care Act to evaluate Medical Necessity and Experimental/Investigational appeals and review Quality of Care issues for state licensing agencies.
Permedion is designated by the Centers for Medicare & Medicaid Services (CMS) as a Quality Improvement Organization (QIO)–like entity and accredited by URAC for both Health Utilization Management and Independent External Review.
For additional information about Permedion please contact info@gainwelltechnologies.com.
Massachusetts Medicaid
MassHealth Acute Hospital Utilization Management Program
Permedion performs utilization management services on behalf of the Executive Office of Health and Human Services, to ensure medical and surgical services provided to members are medically necessary, are delivered in the most appropriate and cost-effective setting, billing is compliant and that members receive the quality of care that is consistent with professionally recognized standards. Components of the utilization management program include the retrospective review of prepayment and post-payment claims as well as pre-admission screening for all elective inpatient hospital admissions.
For inquiries related to this contract, please email maur@gainwelltechnologies.com.
New Jersey Medicaid
NJ FamilyCare Utilization Review Audits
Permedion provides utilization review services on behalf of the New Jersey Department of Human Services, Division of Medical Assistance and Health Services. The scope includes clinical audits of acute care general hospitals, private psychiatric hospitals, comprehensive rehabilitative hospitals and specialty hospitals for both fee-for-service and managed care claims.
For inquiries regarding this contract please email Permedion.NJUR@gainwelltechnologies.com.
Ohio Medicaid
Fee For Service Hospital Utilization Management Program
Permedion supports the Ohio Department of Medicaid’s statewide clinical utilization management and prior authorization program for hospital and other services provided to Ohio Medicaid consumers.
For questions regarding Fee for Service Prior Authorization / Precertification requests, retrospective review or other general questions please email ODMUR@gainwelltechnologies.com.
External Medical Reviews
• Ohio Medicaid Managed Care Entity
• Ohio MyCare (Medicare)
Providers who disagree with a Medicaid Managed Care Entity (MCE) or MyCare Managed Care Entity’s decision to deny, limit, reduce, suspend, or terminate a service due to lack of medical necessity may request an External Medical Review with Permedion. Requests must be submitted within 30 calendar days of the written notice confirming that the Health Plan’s internal appeals process has been completed. Providers may also request a review if the MCE fails to meet required timeframes for a Provider Internal Appeal or Provider Claim Dispute involving medical necessity.
Providers must submit the appropriate External Medical Review Request Form—either the Ohio Medicaid or Ohio MyCare version—along with any supporting documentation not previously submitted to the MCE. Forms and documents can be uploaded through Permedion’s provider portal; new users may email IMR@gainwelltechnologies.com to establish access.
For additional information about the External Medical Review process, contact Permedion
at 1-800-473-0802 Option 2, or email IMR@gainwelltechnologies.com.
Forms:
Ohio Medicaid – Provider External Medical Review Request Form
Download PDF
3 pages; 203 KB
Ohio MyCare Provider External Review Form
Download PDF
3 pages; 203 KB
Ohio Medicaid HomeHealth PriorAuthorization Request Form
Download PDF
3 pages; 246 KB
Ohio Medicaid Inpatient Psychiatric Precertification Request Form
Download PDF
5 pages; 312 KB
Ohio Medicaid Permedion Portal Quick Reference Guide
Download PDF
14 pages; 1 MB
Portal Access Request Form
Download Excel File
1 page; 44 KB