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.

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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.

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• 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.

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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.