This service affords consumers access to federally required due
process when a health care claim or procedure is denied preauthorization
or payment on the basis of medical necessity or appropriateness.
EdiPhy Advisors IRO services enable self-insured health plans, health
plans in federal-process states and state insurance departments to
operate in compliance with applicable regulations and guidelines through
the application of medical necessity and appropriateness criteria.
Private IRO contracts for external review services, to include self-insured plans and plans located in states that have opted for the federal process.
State contracts to serve among the statutory-mandated list of accredited IROs to be assigned external reviews.
Benefits of these services include compliance with Department of
Labor / ERISA guidelines and compliance with state and federal mandates
for external reviews and appeals, and defined medical necessity denials.