Federal & State External Review

OneIRO provides independent Federal and State External Review services for health plans, TPAs, insurers, and other healthcare organizations requiring impartial review of adverse benefit determinations by qualified clinical experts.

Cases are assigned to appropriately qualified, specialty-matched physician reviewers based on the member’s condition, treatment, procedure, or service under review. Our external review services support applicable federal and state requirements and provide fair, objective, and clinically sound determinations.

Services may include:

• Medical Necessity Determinations

• Experimental & Investigational Treatment Reviews

• Adverse Benefit Determinations

• Standard & Expedited External Reviews

• Pharmacy & Specialty Medication Reviews

• Medical & Surgical Services

• Complex & High-Cost Treatments

• State & Federal External Review Requirements