What is IRO: Understanding Independent Review Organizations
IRO: Answering the most common questions
IRO is an acronym which stands for Independent Review Organization. Independent Review Organizations (IROs) are entities that conduct independent external reviews of adverse determinations involving appropriateness of care, medical necessity criteria, level of care, and effectiveness of a requested service
Q: What kind of coverage must I have to use the IRO process?
A:Patients with coverage provided through major medical health insurance plans, including HMOs and PPOs and public employee
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benefit plans can utilize the IRO process.
Q: At what point should I request an external review?
A: When you have exhausted the internal appeal process through your healthcare coverage provider.
Q:Who is on the panel of the Independent Review Organization?
A:Physician Advisors who are experts in the field related to your medical condition will review the case. These Advisors typically go through a rigorous screening and credentialing process before being selected as a Physician Peer Reviewer.
Q: How can I initiate an external review?
A: To initiate an external review, contact your healthcare coverage provider.
Q: Can I request an external review of any denied claim?
A: No. You may request an external review of a denied claim when:
The insurance company has determined the service you want is not medically necessary, is experimental or is investigational
Your provider documents that the service (and all care related to the service) will cost you more than $500 if not covered in the case of a medical necessity decision; and
You request external review within 180 days of being notified about the internal decision.
Q: How long will it take for the external review to be preformed?
A: The IRO must make its decision within 30 days. Decisions must be expedited within seven days if the health condition requires it.
Q: Can I appeal the IROs decision if I am not happy with it?
A: Decisions made by the IRO are final and legally binding