HEALTH PLANS

Expertise Health Plans Can Trust

Engage with a proven partner who aligns with your plan policies.

We Serve Your Members and Providers

As an extension of your team, we serve your members and providers with your guidelines and policies.

Operating a high-performing utilization management (UM) program requires deep clinical expertise, scalable operations, and proactive regulatory knowledge to ensure workflows and staffing evolves to stay compliant.

MRIoA combines same-state licensed clinicians across 150+ specialties with in-house expertise, intake technology, and proven workflows to support your team. Our health, pharmacy, and specialty reviews reduce unnecessary costs and ensure members get the right care.

WHY IT MATTERS

Designed for What Health Plans Need Most

Evidence-based determinations aligned to your policies for consistency
Audit and appeal-ready documentation with clear rationale and clinical support to strengthen defensibility and reduce compliance friction
Better visibility into utilization trends

Versatile UM capacity with predictable service levels without adding permanent headcount or straining existing team
Multi-client configurability across employer groups and lines of business, supporting different benefit designs, plan rules, and client requirements

Services Configured for Your Members

MRIoA’s review services are configured to meet the unique needs of members across multiple lines of business.

Fully Insured

With a full range of health and pharmacy reviews, we use the health plan and TPA policies to ensure care is appropriate and cost effective.

Self-Funded

Our health and pharmacy reviews support self-insured commercial insurance customers, controlling costs and improving outcomes.

Medicare Advantage

Our robust panel for health and pharmacy reviews ensures plans stay compliant and provide access to the right care.

Managed Medicaid

We help managed Medicaid plans stay in compliance with ever-changing state requirements with expert reviews.

Exchange

Our reviews ensure each exchange member gets care decisions through evidence-based clinical review and consistent application of criteria.

How Health Plans Partner with MRIoA

Our consultative approach ensures health plans have access to the review types and specialists needed to meet your team’s needs.

Health Reviews

Our team of clinicians, nurses, and physicians conduct initial reviews, appeals, state and federal reviews. We perform prospective, concurrent, and retroactive reviews. We are an independent review organization (IRO). Our team performs special investigations for fraud, waste, and abuse. We can also provide determination letters.

Pharmacy Reviews

From prior authorization to formulary exceptions, we handle the full pharmacy review spectrum so your team can focus on strategy. We employ and contract with clinicians, pharmacy technicians, licensed pharmacists, and physicians to perform prospective, concurrent, and retroactive reviews, as well as peer-to-peer reviews. Our team leverages expertise for pharmacy and therapeutics committees.

Specialty Reviews

Our panel of 150+ specialists provide expertise to ensure members get appropriate care in specialties such as behavioral health, musculoskeletal, radiology, genetic testing, pain management, sleep medicine, and gender-affirming care.

Nurse Services

MRIoA provides nurse support for utilization and clinical review including prospective, concurrent, retrospective, staffing capacity augmentation and backlog review.

High-Cost Specialty Drug Review

Our experts facilitate a peer-to-peer call between the prescriber and a panel specialist. Through this collaborative review process, we identify clinically appropriate, cost-effective therapeutic alternatives that reduce drug spend without compromising member care.

Peer to Peer

Collaborative discussions between treating physicians and expert medical peers to share insights, clarify clinical information and ensure optimal patient care.

Where Cost Management Meets Clinical Quality

Our unmatched expertise and skilled clinical panel deliver high-quality reviews that improve care while lowering unnecessary costs.

Specialized Expertise & Operational Scalability

Gain access to a deep reviewer panel of reviewers with comprehensive expertise across a range of specialty areas typically not found in house – that scales to meet your volume needs.

Compliance with State & Federal Regulations

Stay compliant by partnering with experts who are steeped in knowledge of the ever-evolving regulatory landscape.

Independent Clinical Rigor

Expand your access to independent assessment of claims, which eliminates possible bias in the review process throughout multiple levels of appeals.

Customer-Centric Operations

Serving as an extension of your team, MRIoA’s service delivery provides review transparency, reporting, and insights needed to ensure high performance.

Quick Turnaround Times

Benefit from quick turnaround times that decrease delays in treatment and administrative burden, improve compliance with regulated processing timelines, and meet peer-to-peer calling requirements.

Secure Data Infrastructure

With HITRUST and SOC2 certification and the latest security controls, we ensure data is transferred, processed, and analyzed with the highest degree of cybersecurity standards.

Perspectives for Health Plans

Blog

03/25/2026

4 Best Practices to Get Better Outcomes and Better Member Experiences

Outsourcing utilization management (UM) used to be a “break glass in case of overflow” decision. Outsourcing served as a response to volume fluctuations, staffing shortages, or when an independent review…

Bre Legler

Blog

01/29/2026

From Policy to Practice: What Today’s Regulatory Shifts Mean for Clinical and Pharmacy Operations

Regulatory change is no longer episodic. It is cumulative, layered, and increasingly operational. Legislative and regulatory shifts are moving quickly from Capitol Hill and state capitols into day-to-day operations. For…

Katie Clark

Blog

09/29/2025

Is your Organization Ready for Fall 2025 State Regulatory Changes?

State legislatures and regulators are moving fast, and for payers, third-party administrators (TPAs), and pharmacy benefit managers (PBMs), the business impact is real. Starting this fall and continuing into early…

Katie Clark

Give Your Members Access to Better Care.

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