First and Second Level Appeals
Changes in regulations for members’ appeals have many organizations searching for
a vendor to provide independent external review services. Health plans, insurers,
and government agencies need a review entity to provide an objective assessment
of the necessity of health care services requested by those insured. The benefit
of independent medical review is to resolve differences in opinion or understanding
between a plan and its clients.
KePRO, through its extensive pool of credentialed physician reviewers, can provide
the required independent assessment using a physician of the same or similar specialty
who has no formal relationship with the insurer, patient, or involved physician/provider.
Our appeals reviews provide an independent decision to support or recommend a modification
of a decision.
KePRO provides first and second level appeals review. We also handle grievances
– written complaints submitted by the member, which challenge any of the following:
- the insurer’s decisions, policies or actions related to availability, delivery or
quality of health care services
- claims payment or handling; reimbursement for services
- the contractual relationship between the member and the insurer
- the outcome of an appeal decision
For more information about KePRO’s first and second level appeal services, contact
our Business Development professionals at 1.800.222.0771, or
email us today.
