Utilization Reviews

Independent Specialty Matched Reviews

Medical Consultants Network is a URAC-accredited Independent Review Organization (IRO). Our network of over 500 expert independent review specialists provides specialty-matched, unbiased Utilization Review determinations while MCN’s non-clinical staff ensure URAC, state, and federal reporting mandates are met within appropriate time frames. MCN’s evidence-based reports streamline Utilization Review determinations for group health plans, workers' compensation, third party administrators, and case management firms. MCN provides independent reviews on both standard and expedited timelines. Service descriptions include:

• Retrospective: conducted after services (including outpatient procedures and services) have been provided to the patient.
• Concurrent: (Continued Stay Review), conducted during a patient’s hospital stay or course of treatment (including outpatient procedures and services).
• Prospective: (Pre-certification Review or Prior Authorization), conducted prior to a patient’s admission, stay, or other course of treatment (including outpatient procedures and services).

Independent Utilization Reviews

Independent Utilization Reviews assist health plans/insurers determine coverage for certain treatments and procedures, level of care, or other administrative issues; such as legal and clinical interpretations of medical policy and contract language eligibility. Outsourcing internal appeals to MCN can reduce your staff costs and increase the quality and expertise of specialty-matched reviews while providing a conflict of interest free report. MCN offers 1st and 2nd level internal appeal utilization reviews and external reviews considering the following:

• Medical necessity or appropriateness of care
• Experimental or investigational treatments
• Administrative reviews / legal and clinical interpretations of medical policy and contract language and eligibility

External Reviews

In addition to independent utilization reviews, MCN also performs external reviews. External Reviews are third party utilization reviews mandated as a final level of consumer protection in health coverage disputes by the Patient Protection and Affordability Care Act (PPACA). After a plan participant has exhausted their health insurance carrier’s internal appeals process, they have the right under state or federal law to request an External Review to be conducted by an Independent Review Organization (IRO). Determinations made in an external review are final and legally binding. As a URAC-accredited IRO with national reach, MCN is uniquely equipped to comply with both Federal and State regulations regarding the external review process.