Case Review FAQs

Enrollees/members of most health plans may request review of coverage denials after they have exhausted the internal grievance process within their plan. Some states have enacted external review laws or regulations governing patient's rights to appeal these decisions. State laws vary greatly over what types of decisions may be appealed by an enrollee/member, so you should contact your health plan or state health or insurance department for assistance.

In some states, the supervising agency (health or insurance department) selects an IRO to review the enrollee's appeal. Other states require insurers to establish an external appeals procedure, whereby the insurer contracts with an IRO. In some states, the supervising agency (health or insurance department) selects an IRO to review the enrollee's appeal. Other states require insurers to establish an external appeals procedure, whereby the insurer contracts with an IRO.

Most states allow for an independent medical review to address coverage disputes involving the medical necessity/appropriateness or experimental/investigational nature of the proposed healthcare service. For more information on State Laws regarding independent reviews, contact your state health or insurance department or your health plan.

The vast majority of states require entities that perform external review to register with the state government. Some states may require that health plans use an IRO that is not only registered with the state but that meets rigorous external review accreditation standards. Your state departments of health and/or insurance should have a list of IROs. IROs are sometimes referred to as EROs (External Review Organizations). You will also find more information on NAIRO's website: www.NAIRO.org

Internal reviews are part of the grievance process managed by health plans and triggered when an enrollee/member appeals non-coverage decisions. IMEDECS reviewers may be asked to provide their insights at this stage. However, IMEDECS does not manage this process nor are the recommendations of its reviewers generally binding.

External review is an independent, medical case review of a health plan coverage denial based on the medical necessity or the investigational/experimental nature of the proposed treatment in question. Members of a health plan may request external review of such denials by an Independent Review Organization (IRO), generally after they have gone through the health plan's internal grievance process - "internal" review. External review is the last step in the appeal process. These reviews are often mandated by state law, and the states may play an active role in the process.

The review is performed by an independent physician/clinician expert reviewer(s). Some states mandate that medical reviews be conducted by a single reviewer or a panel of experts. The expert reviewer is typically board certified by the appropriate American specialty board in the clinical area in question and is qualified to perform his/her functions with respect to the external medical review.

This process varies by state - some states require the patient/enrollee to submit information directly to the health plan, not the IRO. Generally, enrollees may send any information relevant to the independent review to the health plan and/or the IRO. Typically, the information that you send should include notification from the health plan of the denial of the service/treatment at issue, any medical records in support of the request, and a signed authorization form from you or your treating physician.

The IRO is responsible for choosing the appropriate physician/clinician reviewer for each independent review. The IRO may use multiple sources to assign an expert to an individual review. As part of the process, the IRO will ensure that the expert reviewer(s) are free of conflict of interests with the health plan, the enrollee, the enrollee's treating provider(s) who provided or recommended the treatment under review, and/or the manufacturer of the medical device, test, pharmaceutical or biologic in question.

The external review determination generally will be made within 30 calendar days from the time the health plan receives your properly completed request form. The majority of the state external review statutes contain time limits for the appeal. These are generally between 30 and 60 days to complete the process and reach a decision. Some states allow for expedited reviews (3 to 5 days) when your treating physician certifies in writing that the full 30 day period would jeopardize your health.

The professional fee for the review is generally paid by the health plan (except where state law requires members to pay a filing fee as part of the state-mandated program). Members will be responsible for the cost of retrieving and sending the information to the health plan.

Before selecting and contracting with an IRO, most health plans thoroughly review all IRO vendor applications and select vendor(s) based on several factors, including but not limited to: a) maintaining the confidentiality of member medical records; b) screening procedures for determining conflict of interests with physician/clinician expert reviewers; c) accreditation awarded as an IRO; d) verification of personnel qualified to perform reviews (i.e. physician credentials, etc.) and review methodology that includes consideration of published, scientific evidence.

In some states the independent review decision is binding on both the health plan and the enrollee, while in other states, the decision is binding only upon the health plan. Additionally, there are a number of states in which the decision is not binding on either party.

Currently, URAC is the only independent review accrediting organization.

Yes. Hayes Plus was accredited by URAC in May 2000. The Independent Review Organization accreditation was transferred to IMEDECS in 2005.

An evidenced-based review means considering the best available scientific evidence in making decisions about the care of individual patients. Optimal medical care requires both the objectivity of science and the healthcare provider's personal experience.