CareReview / Solutions / Health Review
Expert-Driven Medical Review
Physician-led utilization review, appeals, and URAC-accredited external review for health plans and TPAs.
Expert-Driven Medical Review
Physician-led utilization review, appeals, and URAC-accredited external review for health plans and TPAs.
We provide a comprehensive range of health review services designed to promote clinical quality, appropriate care, and better outcomes across both commercial and government-sponsored health programs.
Our team of experienced physicians and allied health professionals ensures every review is guided by evidence-based standards and the right clinical expertise. Across a broad spectrum of review types, we help organizations make informed decisions. Whether through routine case reviews, peer-to-peer consultations, or large-scale projects with rapid turnaround times, CareReview supports the delivery of appropriate, high-quality care while advancing improved health outcomes for the partners we support.
Core Review Services
Initial Review
Each request is carefully screened for complete documentation, then evaluated by a nurse or physician against clinical guidelines and policy criteria. Our process includes prior authorization and prospective, concurrent, and retrospective reviews to ensure care is medically necessary, appropriate, and effective, with peer-to-peer consultation available when needed.
Appeal Review
When a determination is appealed, a specialty-matched independent clinician reviews the case to ensure accuracy and fairness. Peer-to-peer discussions are available to clarify complex cases and support evidence-based outcomes.
State & Federal External Review
As a fully accredited Independent Review Organization (IRO), CareReview provides final, impartial determinations once all internal appeals are complete—ensuring evidence-based decisions on medical necessity, appropriateness, and effectiveness of care.
Specialty & Advanced Review Services
CareReview provides advanced specialty reviews for complex or high-risk cases requiring focused clinical expertise. This list is not exhaustive—our solutions are flexible and fully customizable to meet each client's unique needs.
Specialty Initial Review
Focused evaluations of high-acuity or complex treatments to ensure clinical appropriateness.
Quality of Care / Level of Care Reviews
Objective assessments to confirm the right level and standard of care for each patient.
DRG Clinical Validations
Expert review of Diagnosis-Related Group assignments to ensure accurate clinical coding and reimbursement alignment.
Fraud, Waste & Abuse (FWA) Support
Targeted reviews to detect fraud, waste, or abuse while protecting clinical integrity.