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An Independent Review is a process where expert professionals are selected to review specific medical decisions made by an insurance company or employer regarding claims determinations. Independent Reviews are a required component of denial management. When the healthcare insurer or employer denies a benefit claim, an IR provides the patient with a system to resolve the issue(s). IROs provided unbiased, neutral decisions about medical care founded solely on the evidence and the medical necessity of a procedure.
There are two levels of IR. First level: are considered first level appeals following initial insurance carrier or HMO decision. These reviews may be conducted pre-service, concurrent or retrospective. Second level: are considered second level appeals, such as a reconsideration of the previous appeal determination. The third level of review is called an External Review; these are conducted at the request of the State Department of Insurance. States that have not adopted a formal ERO Appeal Process must follow the External Review Process as described in the Affordable Care Act.
These reviews are fair and impartial and benefit both the provider and the patient and ensure that the services are provided in the most appropriate manner possible. Types of Review determinations include, but are not limited to:
OFMQ is a URAC accredited independent review organization (IRO). Our review processes meet rigorous URAC Standards as well as state and regulatory requirements. Our expert panel of independent reviewers not only includes physicians but a host of Allied Healthcare Professionals. All of our physicians are board certified in their specialty areas. Our reviewers’ opinions are grounded in evidence-based medicine, clinical research and National Practice Guidelines and standards of care which supports the integrity and defensibility of review outcomes.