Behavioral health
Independent review across psychiatric, substance-use and behavioral health levels of care, from inpatient through community-based services.
Solutions
Independent review across
the healthcare continuum
Flexible clinical review for health plans, administrators, government entities, providers and other healthcare organizations.
Service lines
Twelve review services,
one clinical standard
Every case is reviewed by a physician board certified in the relevant specialty, at every level of review a health plan operates.
Medical
Medical necessity and appropriateness review across specialties, services and settings.
Pharmacy
Formulary exception, prior authorization and specialty medication review.
External review
Independent external review for eligible adverse benefit determinations.
Internal appeals
Specialty-matched review supporting fair and defensible appeal decisions.
Prior authorization
Timely physician review for requested services, procedures and levels of care.
Independent Dispute Resolution
Clinical and administrative support for eligible payment disputes under the No Surprises Act.
Government audits
Medical review supporting oversight, compliance and audit engagements.
CIA reviews
Claims and clinical review supporting corporate integrity agreement obligations.
Workers' compensation
Independent review for work-related treatment and medical necessity questions.
Peer review
Objective specialty review of quality, appropriateness and standard-of-care questions.
Expert medical opinions
Focused clinical opinions for complex or high-impact cases.
Behavioral health review
FOCUS has extensive expertise in conducting behavioral health medical necessity reviews. We maintain a broad panel of board-certified psychiatrists with licensure throughout all 50 states and the District of Columbia. The panel offers subspecialties in child and adolescent psychiatry, geriatric psychiatry and addiction medicine, and includes reviewers with extensive experience managing and reviewing eating disorder services and applied behavior analysis.
We serve both commercial insurance and government programs, and review the entire continuum of care from inpatient treatment through outpatient treatment, including community-based services, ABA therapy, transcranial magnetic stimulation, electroconvulsive therapy, and psychological and neuropsychological testing.
Medical review
FOCUS provides review services for medical utilization management across a wide range of specialties. Physician reviewers are board certified in their respective specialties and all clinicians have extensive experience.
Pharmacy review
Beyond traditional utilization management, our panel supports health plan partners with pharmacy utilization management. We support prior authorization with initial determinations, reconsiderations and appeals, including formulary exception review.
Case shaping and quality of care
In addition to medical necessity review, FOCUS provides case shaping and consultation for complex or co-morbid cases. Every review includes evaluation and discussion of any potential quality of care concerns identified by health plan staff or during clinical review.
A review model built around your requirements
Turnaround times, report formats, clinical criteria, escalation pathways and reporting can be configured to fit each engagement.
Discuss your program