Independent Review
As a URAC-accredited Independent Review Organization (IRO), iMPROve Health provides high-quality, comprehensive, and objective review services to hospitals, third-party payors, health plans, and state insurance departments nationwide. This includes independent external, utilization, and peer reviews. We offer medical leadership services for small and critical access hospitals via our Virtual CMO™ program.
Independent Review
Our in-depth reviews are based on each client’s questions, associated medical records, and clinical information. Our clinical peer reviewers make all decisions based on evidence-based guidelines, where applicable, and in accordance with state statutes and timeline requirements. Learn more about our capabilities as an IRO.
The heart of our independent review program is our qualified professional clinical peer reviewer network. We have more than 400 actively practicing, licensed, board-certified (when applicable), credentialed medical and surgical specialists, including physicians, nurses, physician assistants, advanced practice registered nurses, psychologists, physical therapists, social workers, and pharmacists.
Utilization Review
For more than 40 years, iMPROve Health’s experienced independent review nurses, in collaboration with our expert clinical peer reviewers, have conducted prospective, concurrent, and retrospective prior authorization utilization reviews at all levels. Decision-making is based on current medical evidence, clinical expertise, insurance plan requirements, and treatment-specific guidelines, utilizing criteria such as InterQual and Milliman Care Guidelines.
Prior Authorization Certification Evaluation Request (PACER)
Please note that effective 10/1/2023 iMPROve Health is no longer conducting prior authorization requests for PACERs, negative pressure wound therapy, enteral/parenteral formulas, and infusion therapy for Fee for Service Medicaid and CSHCS. Requests are now being processed by MDHHS at 1-844-722-3764.
Independent External Review
We provide comprehensive independent external review services, including appeals of adverse determinations for medical necessity, investigational/experimental services, cosmetic denials, and health claims. Decision-making is based on standards of care, evidence-based literature and research data, clinical expertise, and/or regulatory requirements. Our expert clinical peer reviewers, in coordination with our independent review team, offer the expertise and experience that ensure our clients receive timely, high-quality, and objective reviews.
Long-term Services and Support
LTSS reviews help Medicaid beneficiaries with chronic illnesses and/or practical limitations live more functional lives. LTSS can be provided in nursing homes, assisted living facilities, rehabilitation facilities, homes, and other community-based settings.
Federal regulations require Medicaid beneficiaries to meet specific Level of Care (LOC) criteria for their benefits to be covered. iMPROve Health performs LOC determinations by reviewing medical record documentation to determine if a beneficiary has met the eligibility criteria required for specified Medicaid services and support.
In addition, iMPROve Health performs nursing assessments on behalf of the Michigan Department of Health and Human Services, Home Help Program. This program provides funding for qualified individuals to hire someone to assist them with their activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Long-term Services and Support
Michigan Fee-for-Service (FFS) Medicaid:
1-800-727-7223
Peer Review
iMPROve Health conducts peer reviews to evaluate if the standard of care has been met by assigning cases to our same specialty-matched clinical peer reviewers. These peer reviews involve a thorough assessment of clinical documentation, adherence to treatment guidelines, and current clinical practice to ensure appropriate care was provided. We also provide peer reviews through our Virtual CMOTM program, which is offered to small or critical access hospitals.
