Independent Peer Review
Let the Experts Take a Look®MCMC offers a wide variety of programs and services that review and evaluate claims. Our vast experience in performing Independent Peer Review has allowed MCMC to develop best practices, which are applied to meet the needs of individual clients.When you partner with MCMC for Independent Peer Review, you access the nation’s largest multi-line provider of independent, evidence-based medical peer review and related services, with access to a combined national panel of more than 1,200 board certified and actively practicing credentialed reviewers, our expert reviewers will focus on your needs.
MCMC provides Independent Peer Review in various markets:
- Group Health
- Workers’ Compensation
MCMC’s URAC accredited, Independent Peer Review division completes over 50,000 reviews each year for more than 400 clients, including BCBS plans, Managed Care Organizations, PBMs, Disability, Workers’ Compensation, and Auto-No Fault insurance carriers as well as Self Insured Employers, Taft-Hartley plans and Federal and state organizations.
MCMC has become the leading independent peer review organization by:
- Focusing on the individualized needs of clients while using sound clinical expertise and evidence based medical guidelines.
- Recruiting a highly qualified panel of credentialed reviewers that allows us to offer matching to the subspecialty level.
- Creating a case processing system that allows us to remain timely for all types of reviews.
- Emphasizing and demonstrating superior customer service.
- Establishing a multifaceted quality assurance and quality improvement program to measure and improve the quality of products and customer service.
- Possessing the financial stability and resources that enable MCMC to meet all client obligations.
Independent Peer Review Services available include:
- Appeals- MCMC reviews previously denied services and provides expert advice for appeals. Reviews include medical necessity, cosmetic, and investigational / experimental procedures and treatments. The reviews meet URAC, NCQA, Federal, and State legislative requirements.
- External Review (State & Federal) - MCMC is certified as an IRO in the following states: Arkansas, Colorado, Georgia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Nevada, New York, Ohio, Oklahoma, Pennsylvania, South Dakota, Washington, Wisconsin.
- Retrospective Review
- Prior Authorization / Pre-Certification
- MCMC reviews authorization for inpatient hospital stays, procedures, and medications. Each review is performed by either a generalist or specialist depending on the claim’s need. Reviews are typically completed in 48 hours or less.
- Fraud Review
- Medical (Forensic) Expert
- Special Projects