Independent review of
adverse benefit determinations

What external review requires

External review sits at the end of the appeal chain. A covered person has exhausted the plan's internal process and the determination moves to an organization with no financial relationship to the outcome. Federal law and state external review programs both impose conditions on who may conduct that review: accreditation, documented conflict-of-interest screening, clinical peer matching, and turnaround standards that do not move.

FOCUS has conducted internal and external review, including formulary exception review, as an accredited Independent Review Organization, and is expanding that work into general federal and state external review.

How FOCUS handles it

Conflict-of-interest screening

describe the actual screening procedure: what is checked, against what sources, at what point in the workflow, by whom, and what is documented

Clinical peer matching

Reviewers are board certified in the specialty relevant to the case, drawn from a panel licensed across all 50 states and the District of Columbia. Where a state program requires licensure in the covered person's state, that requirement is met from the same panel.

Turnaround

standard and expedited turnaround commitments, stated against the applicable regulatory deadline

Documentation and defensibility

Every determination is produced in the Review Management System, which retains the case record, the criteria applied, the reviewer's credentials and the reasoning supporting the determination. That record is what withstands a subsequent challenge.