Independent Review (IRO)

NYCHSRO/MedReview Independent Review Program is URAC accredited and as such follows all URAC guidelines.

WHAT IT IS:

  • NYCHSRO/MedReview provides affordable independent medical reviews to health plans, third party administrators and self-insured companies that require specialty-matched physician reviews. Types of review include:

    • Medical necessity

    • Experimental/investigational

    • Appropriateness of treatment or hospitalization

    • Coding

    • Administrative/legal

  • NYCHSRO/MedReview’s role is to evaluate the submitted material and to render an objective, rationalized, evidence-based decision with inclusion of appropriate references to peer-reviewed medical literature and other appropriate reference material. All physician reviewers must attest that they have no conflict of interest and the MD reviewer sigs an attestation which confirms there is no conflict

HOW IT WORKS:

  • Provides for review by a neutral objective third party of medical reports and other documentation to resolve conflicts arising out of request for provision of health care services and/or related claims and coverage issues

  • Ensures compliance with timeliness requirements for processing of all appeals based on URAC guidelines.

  • Maintains a network of reviewing peer physicians and allied health care professionals covering the majority of ABMS and AOA-defined specialties and related fields

  • The physician reviewer will document as part of their clinical review the criteria and guidelines that were used in the case determination

  • Ensures that reviewers’ determinations are based on review of the necessary medical documentation provided including contact with the treating physician, as may be necessary and appropriate, for clarification of points relating to the issue under review

  • Ensures that reviewers complete written reports within the required deadlines and that reports clearly document the reasoning and evidence which underlie the determination

  • All reviews are completed by physician specialty matched.

  • Once the clinical review is completed the findings are sent to the client

  • The IRO unit has a dedicated secure email address where the clients will send all requests for reviews.

For more information, click here.