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CareReview As Your Independent Review Organization
A plain-English guide to IROs, external review, and what accreditation actually guarantees.
CareReview As Your Independent Review Organization
A plain-English guide to IROs, external review, and what accreditation actually guarantees.
External review is the point where a denial leaves the plan. After internal appeals are exhausted, federal law gives members the right to have the decision reviewed by an organization with no stake in the outcome, and that organization's determination is binding on the plan. Fully insured plans generally follow their state's process. Self-insured ERISA plans follow the federal one, and Department of Labor guidance directs those plans to contract with at least three IROs and rotate assignments among them.
Accreditation is how a plan verifies the organization on the other end. URAC audits reviewer qualification and specialty matching, conflict-of-interest screening, turnaround, and documentation of rationale, on a recurring cycle. What it does not replace is state authority. Many states require separate certification to perform external review for business they regulate, and a plan evaluating an IRO should ask both questions.
CareReview is a URAC-accredited Independent Review Organization and is HITRUST certified. Reviewers are specialty-matched and licensed in the states where review is performed.
Beyond Utilization Management
Payment Integrity
Specialty-matched clinical review that catches inappropriate payments after the claim is paid.
Pharmacy Review
Independent, pharmacist-led coverage determinations and appeals, built for the volumes PBMs and payers manage today.
Workers' Compensation
Independent reviews against ODG, ACOEM, MTUS, and state guidelines, from specialty-matched physicians.
Independent Medical Exams
Objective, board-certified IMEs, specialty-matched to resolve medical questions with confidence.
Life & Disability
Fair, accurate, and objective evaluations of a claimant's functional abilities, aligned with current standards of care.
Specialty Bill Review
Clinical expertise and national benchmarks applied to complex, high-dollar bills for defensible savings.
The independence that makes an external review binding is not something we switch on for those cases. Every review runs through the same URAC-accredited, HITRUST-certified infrastructure: a specialty-matched clinician with no history on the case and no stake in the outcome, and a rationale documented well enough to defend.