Medical Reviews

Medical Necessity, Experimental/Investigational and Benefit Cases

Works with with State, FEP, Medicare and ERISA Cases

Medical Necessity, Experimental/Investigational and Benefit Cases

Meets Expedited and Standard Time Frames

Medical Necessity, Experimental/Investigational and Benefit Cases

Meets Expedited and Standard Time Frames

Frequently Asked Questions

What is a Peer Review?

Peer review, independent medical review, hospital peer review, and/or medical peer review have become interchangeable terms in the healthcare industry.

Various organizations have their own way of defining these reviews however, the essential function is to obtain an unbiased medical determination not exclusive to a particular procedure, medication, and/or treatment.

Typically, independent reviews occur after all appeals mechanisms available within a health benefits plan have been depleted.

What is the difference between an Internal and External Review Organization?

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.

What is the Review Process?

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.

Why CPHCR?

By contracting with CPHCR, health plans can alleviate any perception of bias that would arise from overlaying social and professional relationships amongst health plans and hospital medical personnel. CPHCR serves as a impartial third party in completing ALL reviews.

Ultimately, CPHCR can decrease payor administrative expenses while ensuring patients receive the most suitable medical treatment.

Independent Review Organization

Medical Reviews

Medical Necessity, Experimental/Investigational and Benefit Cases

Medical Necessity, Experimental/Investigational and Benefit Cases

Medical Necessity, Experimental/Investigational and Benefit Cases

Works with with State, FEP, Medicare and ERISA Cases

Medical Necessity, Experimental/Investigational and Benefit Cases

Medical Necessity, Experimental/Investigational and Benefit Cases

Meets Expedited and Standard Time Frames

Medical Necessity, Experimental/Investigational and Benefit Cases

Meets Expedited and Standard Time Frames

Dynamic Compliance Program

Frequently Asked Questions

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