External IRO

EdiPhy Advisors, LLC

External IRO for Consumers, Self-Insured Plans, Health Plans in Federal-Process States and State Insurance Departments

This service affords consumers access to federally required due process when a health care claim or procedure is denied preauthorization or payment on the basis of medical necessity or appropriateness.

EdiPhy Advisors IRO services enable self-insured health plans, health plans in federal-process states and state insurance departments to operate in compliance with applicable regulations and guidelines through the application of medical necessity and appropriateness criteria.

  • Private IRO contracts for external review services, to include self-insured plans and plans located in states that have opted for the federal process.
  • State contracts to serve among the statutory-mandated list of accredited IROs to be assigned external reviews.

Benefits of these services include compliance with Department of Labor / ERISA guidelines and compliance with state and federal mandates for external reviews and appeals, and defined medical necessity denials.