Medical Review & Appeals

Medical Review & Appeals

Independent medical review services supported by a national panel of board-certified physician reviewers across 48+ states and 60+ specialties.

Review Types

• Medical Necessity
  Evaluating the clinical appropriateness of services, treatments, or procedures based on evidence-based criteria.
• Level of Care
  Determining the medically appropriate setting for patient care, including readmission and continued stay authorizations.
• DRG Validation
  Verifying the accuracy of Diagnostic Related Group coding assignments against clinical documentation.
• Clinical Validation
  Assessing clinical records to substantiate documented diagnoses and ensure objective clinical accuracy.
• Audit
  Conducting comprehensive clinical healthcare audits to ensure adherence to established medical standards and guidelines.

Appeals

• 1st, 2nd, or 3rd Level Appeals
  Delivering comprehensive, conflict-free dispute resolution across all stages of the grievance and appeal lifecycle.
• Internal or External Reviews
  Providing independent, objective determinations for both internal administrative reviews and binding external independent reviews.