Independent Review
As an Independent Review Organization (IRO), iMPROve Health is URAC-accredited with extensive experience in external review, long-term services and support, utilization review, and medical leadership services for small and critical access hospitals (Virtual CMO™).
The heart of our independent review program is our qualified professional clinical reviewer network. It comprises more than 400 licensed, board-certified, and credentialed physicians and other clinicians — such as nurses, physician assistants, nurse practitioners, physical therapists, social workers, and pharmacists — representing most medical specialties and sub-specialties.
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 Review
Healthcare organizations depend on Independent Review Organizations (IROs) to deliver unbiased, third-party medical reviews based solely on the most current medical evidence. As a URAC-accredited IRO, iMPROve Health provides high-quality, comprehensive, and objective review services to hospitals, third-party payors, health plans, and state insurance departments nationwide. These reviews may be prospective, concurrent, or retrospective, and they can center around a single medical event or multiple incidents of care. Our in-depth reviews are based on each client’s questions, associated medical records, and clinical information. Our clinical reviewers make all decisions based on evidence-based guidelines, where applicable, and in accordance with state-specific content and turnaround time requirements.
External Review
We provide various comprehensive external review services based on standards of care, evidence-based literature and research data, and/or regulatory requirements. Our external reviews offer the expertise and experience that ensure our clients receive timely, high-quality, and objective reviews.
Medical Necessity
For treatment or services that may have been deemed experimental, investigational, or cosmetic by a healthcare plan.
Criteria for Coverage
For treatment or services that are not covered or deemed non-compliant with the language of a healthcare plan’s contract.
Quality of Care
Where a peer reviewer provides an expert opinion as to whether the care rendered by a practitioner meets the accepted standards of care.
Long-term Services and Support
Long-term services and support (LTSS) help Medicaid beneficiaries with chronic illnesses and/or practical limitations live a more functional life. These services and support 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 a Level of Care Determination (LOCD) by reviewing medical documentation to determine if a beneficiary has met the criteria required to be eligible for specified Medicaid services and support.
Long-term Services and Support
Michigan Fee-for-Service (FFS) Medicaid: 1-800-727-7223
