Independent Review of Appeals

For assistance in meeting the new requirements under the Patient Protection and Affordable Care Act (PPACA), please contact Terese Giorgio, Senior Director of Corporate Programs, at 516-326-7767, ext. 223

URACIPRO’s review process ensures that every appeal:

  • Receives a thorough review by a board certified clinical specialist who has expertise in the medical area under review, and who is independent of any conflict of interest.
  • Meets URAC standards as well as all requirements established by the Department of Labor’s Final Rule on Claims and Appeals.
  • Is reviewed in accordance with the best available evidence-based medicine.
  • Is tracked through an established process that ensures that determinations are made within contract time frames.
  • Is handled in a way that ensures the privacy of medical information.
  • Results in a fair and impartial determination that is fully substantiated and consistent with nationally recognized standards.

IPRO has performed tens of thousands of reviews for medical necessity and appropriateness and has extensive experience handling appeals of denial of care and payment. IPRO makes objective determinations on appeals covering the full range of disputes among enrollees, providers and health plans such as eligibility, contract interpretation, medical necessity and experimental/investigational treatment.

IPRO is certified to conduct independent external appeals in fifteen states and the District of Columbia. IPRO also reviews appeals on a national scope for ERISA plans.

IPRO has developed and trained a multi-state panel of more than 300 board certified specialists who represent almost all medical specialties and sub-specialties and can provide a full range of clinical reviews.

IPRO’s documentation and tracking processes ensure consistency in review determinations regarding medical necessity and experimental treatments and include safeguards to ensure that decisions are being made fairly and consistently.

In every external appeal/independent review contract, IPRO has met or exceeded contractual requirements for appeal turnaround time.

As one of the first organizations to be accredited as an Independent Review Organization by URAC, IPRO has been in the forefront of conducting independent review programs and has helped set the standard for quality in the external review process.