Case Review Services

All reviews are performed on a patient-specific basis by an expert medical practitioner of the same or similar specialty as that of the treating practitioner. The review methodology employed may be evidence based, criteria based, opinion only, or benefit coverage.

Predetermination Review

• Conducted prior to the referring entity's coverage determination
• Review is consultative/advisory in nature, not determinate or binding

Internal Review - Level I and Level II

• Initiated when a patient or patient's representative appeals a denial of coverage (first or second level appeal or grievance)
• IMEDECS provides an independent, expert peer practitioner to review the coverage dispute
• Review is consultative/advisory in nature, not determinate or binding

External Review - Level III

• Address coverage disputes involving the medical necessity/appropriateness or investigational/experimental nature of the proposed healthcare services
• Requested by patients or patients' representatives after the internal grievance/appeal process has been exhausted
• In most states, decisions of the reviewers are determinate in nature and binding on the plan