Review assignment
Open a medical review from a case audit and assign a clinical reviewer, coding reviewer, and QA analyst for each claim, individually or in bulk.
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AEGIS ISD Medical Review
Clinical review, coding review, QA, and statistically valid sampling.
Medical Review gives clinical and coding reviewers a structured workflow for claim-level and line-level decisions. It covers QA verification, appeals, medical records, and statistically valid random sampling, and stays linked to the investigation it supports.
Line-level decisions
QA verification
Appeals
SVRS + extrapolation
Review workflow
Structured review from assignment to final decision.
Configurable MR workflow
Medical review stages, substages, and approvals are configured per program. A closure-readiness check comes before close, and the linked case audit status advances automatically.
Line-level decisions
Record a decision, reason code, and rationale for each claim line, with internal comments, bulk edit, and a per-line audit history.
Coding review
Coding reviewers record the allowed code and modifiers on each line alongside the clinical decision.
QA verification
Clinician-complete, QA verify, and finalize steps, with QA revisions and a dedicated QA queue on the medical review team board.
Appeals and re-reviews
Track appeals through each appeal level with linked tabs, re-review eligibility checks, and consistent numbering.
Send back to the case team
Return a review to the case team with a required message. Pending approvals are withdrawn and dependent stages pause until the review comes back.
Medical records
A medical review document workspace with folder templates, an in-line document viewer, and document requests sent to providers through the Provider Portal.
Oversight and reporting
Medical review team board, notifications, and dashboard widgets for throughput, aging, reviewer workload, and SVRS compliance, plus review and claim exports.
SVRS sampling and documentation
Statistically valid random sampling, documented for audit.
Size, draw, and extrapolate claim samples with a method that is aligned with OIG RAT-STATS and recorded in the case file. Sampling works from the case's claim universes in Case Management.
State Medicaid program integrity units: see Medicaid program integrity software.
What the sampling engine does
- Sample size by Cochran's formula with finite population correction, at 90%, 95%, or 99% confidence
- Seeded Fisher-Yates simple random selection, with the seed retained so the draw can be reproduced
- Mean Per Unit extrapolation of overpayment findings
- Probe, nested, and member-universe samples with a one-sided 90% lower confidence bound (Student's t)
- Extrapolation worksheets saved as append-only runs
- SVRS methodology PDF, extrapolation PDF, and claims workbook, saved to the case documents
- Organization-wide sampling defaults set by administrators
Works with
One platform, connected products.
Shared identity, permissions, tenant isolation, and audit history across every AEGIS ISD product.
Case Management
Reviews open from case audits and report back into the investigation.
Explore Case ManagementProvider Portal
Request medical records from providers and receive them securely.
Explore Provider PortalAEGIS Drive
Medical records and review documents with version history and permissions.
Explore DriveWho it's for
Built for clinical and coding reviewers.
- Medical review and clinical audit teams
- Certified coders and coding reviewers
- QA analysts
- Program integrity departments
- Recovery teams relying on extrapolated findings
What the demo covers
- Assigning reviewers, coders, and QA analysts in bulk
- Line-level decisions with reason codes and rationale
- QA verification, appeals, and send-back
- Requesting and viewing medical records
- Drawing an SVRS sample and running an extrapolation
- Medical review dashboards and exports
FAQ
Common questions about AEGIS ISD Medical Review.
Is Medical Review a separate product from Case Management?
Yes. Medical Review is licensed and enabled as its own product. Reviews open from case audits, so it is deployed alongside Case Management, and the review status keeps the linked case audit up to date.
How do reviewers record decisions?
Each claim line gets a decision, a reason code, and a rationale. Reviewers can bulk edit lines, add internal comments, and see the history of every change to a line.
How does QA work?
After the clinician marks a review complete, a QA analyst verifies and finalizes it or sends it back for revision. QA work appears in its own queue on the medical review team board.
What does SVRS sampling need?
Sampling draws from the claim universes on a case, so it uses Case Management claims together with the claim sampling capability enabled for your organization.
How do we get medical records from providers?
Reviewers send and track document requests through the Provider Portal from the medical review records tab.