OUR SERVICES
Get quality-focused reviews with a fast turnaround time. Our diverse range of experts are ready to help healthcare organizations achieve improved outcomes while lowering costs.
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OUR TEAM
We put people at the center.
We keep people at the heart of everything we do.
Our expert clinicians make the clinical determinations, our teams ensure every review meets the highest quality standards, and our leaders guide the utilization management process with clarity and purpose. Most importantly, we never lose sight of the patient as a person—every decision is made with their best care in mind.
We employ more clinicians than most of our competitors and proudly partner with a diverse panel of 700+ state-matched specialists, ensuring expertise, scale, and compassion in every review.
250
internal clinicians
700
panel specialists
One Team, Many Types of Reviews
We deliver high-quality, expert clinical reviews, regulatory guidance, and actionable insights for a wide range of review types. Our diverse team enables our clients to:
Deliver timely, appropriate care
Reduce unnecessary costs
Improve provider and member satisfaction
Navigate complex regulatory and compliance requirements
Leveraging the largest panel of actively practicing, same-specialty physicians and clinical experts with licenses in all 50 states, MRIoA offers configurable services that leverage innovative ways to boost efficiency and improve outcomes. With our clinical and regulatory expertise, we have earned certifications from HITRUST, NCQA, URAC, and UR licensing in all states where required. Our commitment to excellence and security supports our clients’ efforts.
OUR SERVICES
Services Configured for Your Success
We offer the type of review you need – when you need it – to best serve your members.
Clinical Reviews
Our configurable clinical review services are designed to meet the full spectrum of clients’ needs – from a steady volume of health and pharmacy reviews to urgent overflow volume to highly specialized reviews. Leveraging our extensive nationwide reviewer network, our team provides access to state-matched physicians and pharmacists in 50 states with 150+ specialties. Our team delivers timely, high-quality support for standard and expedited reviews, appeals and grievances, peer-to-peer consultations, and specialty reviews across every line of business.
Initial Review
In the initial screening, non-clinical staff ensure the request is complete and has the needed data. Then, a nurse, clinical peer, or physician (as required) performs clinical evaluation of a healthcare service, medical drug, treatment, or admission request using the health plan or organization’s applicable policy and criteria. They determine whether the requested service meets established standards of medical necessity, appropriateness, and effectiveness. A clinical peer can also conduct a reconsideration and/or peer to peer review. We conduct initial prospective, concurrent, and retrospective utilization review.
Appeal Review
Our team conducts an appeal of an adverse determination regarding coverage of a healthcare service or treatment. This review is conducted by a specialty-matched, appropriately licensed, or certified clinical peer who was not involved in the initial decision, ensuring an independent and clinically relevant evaluation. The reviewer can conduct a peer-to-peer review.
State & Federal External Review
We serve as an independent review organization (IRO) and perform state and federal external reviews. This is a
final and binding review that occurs only after the health plan or organization’s internal appeal process has been completed, and it provides an impartial determination regarding medical necessity, appropriateness, and effectiveness of a healthcare service.
Initial Review
In the initial screening, non-clinical staff ensure the request is complete and has the needed data. Then, a pharmacy
technician, pharmacist, (or physician as required) performs clinical evaluation of the requested prescription drug using the Pharmacy Benefit Manager, health plan, or organization’s applicable policy and criteria. They determine whether the requested drug meets established standards of medical necessity, appropriateness, and effectiveness. A clinical peer can also conduct a reconsideration and/or peer to peer review. We conduct initial prospective, concurrent, and retrospective drug UM.
Appeal Review
Our team conducts an appeal review of an adverse determination regarding coverage of a prescription drug using the client’s guideline criteria. This review is conducted by a clinical pharmacist or by a specialty matched, appropriately licensed or certified, clinical peer reviewer (as required) who was not involved in the initial decision, ensuring an independent and clinically relevant evaluation. The pharmacist can conduct a reconsideration, appeal, and/or peer-to-peer review.
State & Federal External Review
We serve as an independent review organization (IRO) and perform state and federal external reviews. This is a final and binding review that occurs only after the PBM or organization’s internal appeal process has been completed, and it provides an impartial determination regarding medical necessity, appropriateness, and effectiveness of a prescription drug.
Clinical Solutions
ClearPath UM™
ClearPath UM connects clinical utilization management with your member care delivery team to improve member outcomes, reduce medical and administrative cost, increase provider and member satisfaction, while ensuring regulatory compliance to all federal and state requirements.
MyCareChoices™
MyCareChoices™ Second Opinion solution is a digital healthcare platform that seamlessly integrates into the prior authorization process and provides members with reliable second opinions and more options.
High-Cost Specialty Drug Review
Our program integrates into the prior authorization process and allows our experts to facilitate a peer-to-peer call between the prescriber and a panel specialist. Our expert will review the prescribed medication and offer therapeutic alternatives that are less expensive for the member.
PA Optimization
Enables health plans to design and manage a better prior authorization solution by delivering a customized CPT code-level ROI assessment of prior authorization programs that enables health plans to manage a more targeted prior authorization list.
Regulatory Guidance
Our regulatory experts perform proactive monitoring of state and federal laws and regulations. We identify and address the operational changes that we and our clients need to make to stay compliant with all requirements. We share timely updates on regulatory changes, enabling clients to adjust staffing and processes. Our strong commitment to innovation and flexibility – both in our processes and our products – ensures that we stay ahead of legislative changes and new regulations.
Specialty Solutions
Our team brings the expertise and credentials needed to deliver clinical reviews across a wide range of specialties and sub-specialties. Our nationwide network includes credentialed, state-matched specialists in 150+ specialties, ensuring the right expertise is applied to every review. We provide comprehensive utilization management services, offering multiple types of reviews to meet our clients’ diverse needs.
Behavioral Health
Our team performs objective, professional reviews of outpatient and inpatient behavioral health claims. The reviews are performed by licensed, certified behavioral health practitioners, such as psychiatrists, psychologists, and mental health counselors.
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Muscoloskeletal
Musculoskeletal treatments have a high incidence of variations in care. With our internal expertise with musculoskeletal conditions and our robust panel of specialists, we conduct reviews to ensure members receive evidence-based, appropriate, and cost-effective care. We can also incorporate a second opinion service to support members, leading to better choices and better outcomes.
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Genetics
Genetic testing and genetic-based treatments are rapidly expanding. We focus on ensuring genetic services are appropriately used, leveraging the health plan or organization’s policies and criteria.
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Pain Management
Chronic pain is the most common reason adults seek medical care, and it contributes to high healthcare costs. Our team reviews medical and pharmaceutical treatment with evidence-based care and healthcare organization policies to reduce the variability in prescribing practices, lowering healthcare costs, and improving care outcomes.
Medical Imaging
Our client review expertise includes evaluating whether requested imaging tests are medically necessary, appropriate, and efficient. Our team reviews a patient’s clinical information and compares it against client-provided, evidence-based guidelines to determine if the imaging service is justified before it is performed. This program helps control costs by preventing unnecessary tests and improves member outcomes by focusing on effective treatments.
Sleep
Our team performs UM reviews of sleep medicine procedures, treatments, and drugs. We leverage the expertise of same-state licensed nurses, physicians, and pharmacists who specialize in sleep medicine. We ensure that members receive appropriate and effective sleep-related treatments.