Independent Medical Review
State departments of insurance and the Affordable Care Act (ACA) have granted individuals the right to an independent, external 3rd level appeal of adverse coverage determinations by their health plans. These appeals are generally initiated for issues of medical necessity, experimental/investigational treatments, pre-existing conditions, long-term care benefit triggers, and rescission of coverage.
As a URAC-accredited Independent Review Organization, we follow strict policies and procedures and adhere to stringent timelines for issuing binding determinations for both expedited and standard reviews.
Determinations of medical necessity and experimental/investigational treatments are made by board-certified, actively practicing, specialty-matched peer physicians and allied health professionals, and are all based on medical evidence: the peer-reviewed published literature, national and society guidelines, authoritative texts and references, and the standards of care. Contract issues are reviewed by actively practicing attorneys with healthcare expertise.
All reviewers are independent contractors with no conflicts of interest or financial interest in the outcome of the determination. Additionally, all reviewers must pass a rigorous credentialing process including primary verification of credentials and professional background checks.