IRO Solutions

MCN’s URAC Accredited Independent Review Organization solutions support health plans and payers in the group and individual markets.

The power of a second look.

Initial and Appeal Level Reviews

Prospective, concurrent or retrospective reviews address medical necessity, experimental or investigational treatments, and/or individual plan language. Some are required to determine whether a plan will cover a procedure or can be conducted when a patient appeals a previous denial.

A doctor wearing a white coat and stethoscope, sitting at a wooden desk, writing in a notebook. There are medication blister packs, a smartphone, and notebooks on the desk.

Coding Reviews

Audits on CPT coding practices, reviewing medical records for appropriateness, upcoding, unbundling and other coding concerns.

A woman in a pharmacy reaching for medication from a shelf.

Formulary Exception Reviews

Addressing whether or not a drug, not currently on a plan’s formulary, is medically necessary in light of the alternatives.

A man in a white lab coat sitting at a desk with a computer, holding papers and looking down, with a colorful patterned curtain in the background.

Quality of Care/External Quality Reviews

An aggregated analysis, validation, or evaluation of the quality, timeliness of, and access to services with a provider facility or health care organization.

Medical professional discussing brain scan results with a patient in an office setting.

Independent Provider Audits

Comprehensive, globally-focused audits on a provider’s treatment, documentation, and billing/coding practices across a sampling of patients.

Open drawer of a filing cabinet filled with index cards.

Fraud, Waste and Abuse Reviews

Completed in conjunction with Corporate Integrity Agreements (CIAs) or reviews to assist with Utilization Management or in identifying fraud, waste, and abuse.

A collection of vinyl records stored upright in black storage bins, with some album covers visible.

Medical Policy Reviews

A policy memo review confirming that a particular treatment or diagnosis aligns with current clinical research and standard of care.

A person typing on a laptop with a stethoscope resting on the desk in front.

Peer to Peer Discussions

When a specialty matched peer discussion with the treating provider is deemed beneficial.