CareReview / Who We Serve / Health Plans
A Clinical Extension Health Plans Can Trust
Accurate, evidence-based review at speed — freeing medical directors for strategic priorities.
A Clinical Extension Health Plans Can Trust
Accurate, evidence-based review at speed — freeing medical directors for strategic priorities.
Health plans bring us three problems: volume that outpaces the internal team, cases outside the specialties their panel covers, and decisions where the plan cannot credibly review its own determination.
Each has a different answer. Prior authorization support returns capacity to medical directors without adding headcount. Appeals go to specialty-matched physicians with no history on the case, which is what makes the determination defensible when it is challenged. External review runs through our accredited IRO, where the independence is structural rather than procedural. What holds across all three is the standard: written, evidence-based rationale that survives audit or challenge.
The Pressure
- PA volume growth strains medical directors and internal clinical teams, with peer-to-peer requests consuming capacity that should go to strategic priorities.
- When the same team reviews its own prior decisions, appeals lack independence and credibility — and backlogs create ERISA compliance liability.
- Federal external review must be assigned to an accredited, independent IRO. That independence is structural, and no plan can replicate it internally regardless of what it invests in internal firewalls or process controls.
- Inappropriate denials expose plans to ERISA challenges and regulatory audits.
- Department of Labor guidance directs self-insured plans to rotate external review assignments among at least three IROs, but most plans carry only one or two — leaving no depth when volume spikes or a case falls outside the existing panel's specialty coverage.
How CareReview Helps Health Plans
We help health plans deliver accurate, evidence-based prior authorization decisions at industry-leading turnaround speeds — freeing medical directors to focus on strategic priorities. For appeals, independent specialty-matched physicians protect plan integrity and reduce ERISA exposure through objective, defensible determinations. For federal and state external review, our fully URAC-accredited IRO platform provides impartial, final determinations for any case, in any state.
Accredited, Specialty-Matched Review
URAC IRO accreditation, available nationally, with specialty-matched, actively practicing clinicians — not generalist reviewers.
True Independence
Independent from all prior PA decision-making, with no financial stake in approval or denial outcomes.
Fast, Documented Determinations
Industry-leading turnaround times that consistently meet regulatory deadlines, with written, evidence-based rationale on every determination.
Federal external review requires an accredited, independent IRO — independence that's structural, not something a plan can build internally at any cost. CareReview meets that bar as a fully URAC-accredited IRO, and gives self-insured plans the specialty depth and case capacity that Department of Labor rotation guidance assumes: a ready third (or fourth) IRO relationship that absorbs volume spikes and covers specialties outside your existing panel, so DOL rotation requirements never leave a gap.
Credentials You Can Rely On
- URAC-accredited IRO, available in all 50 states.
- HITRUST certified — enterprise-grade data security and privacy.
- NCQA accreditation expansion underway, adding to CareReview's URAC, HITRUST, and 50-state credential set.
- Stradix® platform: seamless case submission, tracking, and reporting for health plan workflows.
- One partner covering medical and pharmacy external reviews, prior authorization, appeals, and payment integrity.