Independent Review Organization
Your go-to resource for navigating the complex world of health insurance and empowering you to assert your rights
Our expert team conducts thorough evaluations of Medical Necessity, Experimental/Investigational treatments, Benefit coverage, as well as reviews for State, FEP, Medicare, and ERISA cases.
Our Exceptional team comprises highly qualified professionals, including Board-certified Physicians, Certified Coders, Bill Review Specialists, and Ancillary Healthcare Providers. With their extensive expertise and experience, we are well-equipped to meet your organization's needs.
Our commitment is reflected in our URAC accreditation, signifying adherence to rigorous quality standards and exceptional care. Additionally, as a member of the National Association of Independent Review Organizations (NAIRO), we actively promote transparency and fairness in the healthcare industry, benefiting patients and stakeholders alike.
Our goal is to empower individuals by offering a reliable and independent review process, ensuring that healthcare decisions are made with the utmost integrity and consideration for the well-being of the members they serve.
Our team is committed to streamlining the review process without compromising the quality and thoroughness of our assessments. We understand the importance of prompt resolutions and strive to provide our clients with the necessary support and expedited attention they deserve.
We uphold a proactive approach to compliance, ensuring adherence to applicable state and federal laws and regulations. We are committed to staying updated with evolving requirements and swiftly addressing any concerns to maintain alignment with state and federal standards.
With a vigilant commitment to compliance, we aim to provide our clients with peace of mind, knowing that their healthcare reviews are conducted in full accordance with the latest requirements.
We offer state-of-the-art proprietary software that is tailored to meet clients' unique needs, ensuring seamless operations and streamlined healthcare review management.
With HIPAA compliance, regular SOC audits, comprehensive penetration testing, and our pursuit of HItrust certification, we prioritize robust data protection and uncompromising security.
CPHCR CEO: Brent O'Connell MD
It's important to know that if your health insurance provider denies a claim or terminates your coverage, you have the right to appeal their decision.
Refer to our "member guide" for further details and to explore our streamlined approach for navigating the insurance review process.
In the healthcare industry, you may come across different terms like peer review, independent medical review, hospital peer review, or medical peer review. These terms are often used interchangeably, but they all mean the same thing.
Basically, these reviews serve one important purpose: to get an unbiased medical decision that isn't tied to any specific procedure, medication, or treatment. They are meant to be fair and impartial.
Typically, independent reviews happen when you have exhausted all the options for appeals within your health benefits plan. So, if you've tried everything else and still need a neutral opinion, an independent review can help.
It's important to understand that these reviews exist to make sure you're getting the right medical care without any bias. They provide an extra level of assurance and fairness in the healthcare system.
Internal Reviews are reviews conducted by the same organization that provided the care.
External Reviewers are reviews conducted by an outside organization that was not part of the provision of care process.
Experience the power of Internal Reviews, conducted within your organization, providing valuable insights into the care process.
Unlock even more potential with External Reviewers, independent experts from outside organizations, offering objective evaluations.
Discover the winning combination of comprehensive internal and external reviews at CPHCR.
CPHCR receives a referral from a Health Plan.
The Health Plan will outline the diagnosis, proposed course of treatment, anticipated procedures, date of treatment, and environment in which the procedures will be done.
CPHCR case manager will review the documentation and assign the appropriately qualified physician reviewer who will evaluate the submitted materials against nationally recognized criteria and the claims payers’ benefit allowances.
After clinical review by a qualified physician, a decision is made as to whether or not the procedure is medically warranted. If the procedure, treatment, and/or medication is not deemed medically appropriate, a rationale is provided to include alternative treatment methods.
CPHCR will provide written confirmation of the determination to the patient, health plan, attending physician and/or hospital in accordance with nationally recognized standards.
By partnering with CPHCR, health plans can effectively address concerns related to bias that may arise due to personal and professional relationships between health plans and hospital medical personnel. CPHCR acts as an unbiased third-party entity, conducting comprehensive reviews of all cases.
With CPHCR, health plans can not only mitigate any perception of favoritism but also enhance their reputation for fair and impartial decision-making. This distinction sets them apart from other providers and establishes trust among patients and healthcare providers alike.
Furthermore, collaborating with CPHCR offers significant benefits in terms of cost savings and administrative efficiency for payors. By leveraging CPHCR's expertise, health plans can streamline their processes and ensure that patients receive the most appropriate and effective medical treatments. This commitment to optimized healthcare outcomes is a powerful selling point for health plans and can significantly increase their web traffic and overall visibility.
To learn more about how CPHCR can help health plans enhance their decision-making processes, reduce costs, and improve patient care, contact us today.