External review
Independent external review of adverse benefit determinations under state programs and the federal process, by reviewers with no interest in the outcome.
Professional • Independent • Clinically Astute
Your independent review journey
starts with FOCUS
FOCUS Health delivers behavioral health, medical and pharmacy utilization review for health plans and government programs, through a nationwide panel of board-certified physicians and a review management system we built and own.
With FOCUS, it’s simple™
URAC
Accredited Independent Review Organization (IRO)
HITRUST r2
Certified review management system
NAIRO
Member organization since 2019
FHIR
Health data interoperability standard
Why FOCUS
Clinical expertise
strengthened by technology
The model is built around independence, quality, speed and transparency rather than volume alone.
Physician-led
Clinical leadership sits at the centre of operations, reviewer standards and final report quality.
Automated quality assurance
Readability analysis, rationale checks, workflow controls and human oversight support every review before it is released.
Real-time insight
Clients get timely access to operational metrics, case status and statistical reporting rather than a monthly summary.
Performance
The numbers that decide contracts
Turnaround, panel size, coverage and volume are what a utilization management director scores during vendor selection. No competitor can copy a real number.
0States and DC covered by licensed reviewers
median TATMedian turnaround against contractual standard
panel sizeBoard-certified physicians on the active panel
cases reviewedCases reviewed in the last full year
Inside a review
A disciplined process
from intake to delivery
Every case moves through controlled clinical and quality checkpoints designed to produce consistent, defensible reporting.
Controlled clinical and quality checkpoints
Appropriate reviewer matching
Specialty, licensure, experience and conflict requirements drive every assignment.
Evidence validation
Applicable criteria, plan policy and current clinical evidence are incorporated into the review.
Quality assurance
Reports pass workflow, readability and rationale checks before release.
Review journey
Six controlled steps.
One clear decision.
Case received
Secure intake and validation
Reviewer assigned
Specialty and credential matching
Clinical review
Independent medical analysis
Evidence applied
Criteria and literature support
Quality assurance
Structured report validation
Report delivered
Timely client access
Beyond health plan review
Independent judgment where
the stakes are regulatory
The same panel and the same platform support review in three markets where independence is a statutory or contractual requirement.
Independent Dispute Resolution
Payment dispute resolution under the No Surprises Act, supported by clinical review capacity and a documented, auditable determination process.
Government audit and CIAs
Independent clinical review supporting corporate integrity agreements, where the reviewing organization must be demonstrably independent of the entity under obligation.
Ready to review the FOCUS way?
Tell us your specialty mix, turnaround requirement and level of review, and we will tell you plainly whether FOCUS is the right panel for it.
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