As a URAC Accredited Comprehensive (Internal & External) Review organization, ProPeer is at the forefront of providing clinical review services to health plans, managed care organizations, pharmacy benefit managers, and third party administrators looking to ensure the highest quality and timely appeals process. When plan coverage disputes arise, our clients rely on ProPeer to support their utilization management and appeals by processing effective, accurate independent clinical reviews. We support all levels of appeal for internal, state external, and federal external appeals, as well as various peer review services optimized for enhanced client experience.
Licensed in state mandated external review participating states.
Experienced partner in compliancy with:
• DOL
• ERISA
• ACA
• NAIC Model Act
• Medical Necessity
• Pharmacy/Formulary
• Experimental & Investigational
• Independent Dispute Resolution
• Recission
• Plan/Policy Review
• Panel Review
• Three Party Dispute Resolution
ProPeer’s over 30 years of clinical review experience provides clients with peace of mind knowing a highly qualified team of clinical reviewers will deliver with speed and efficiency, while never compromising quality.
Elimination of potential conflicts of interest including professional, organizational, and/or personal bias inherent to review programs performed or supported with internal reviewers.
Removal of the administrative burden and strain on internal quality assurance/risk management programs by providing efficiency and mitigating the fixed staffing cost of these internal initiatives.
Providing access to a broad range of specialties in instances when facilities’ in-house expertise may be limited.
Objectively monitoring and measuring the quality of care delivered, allowing for benchmarking which can provide the foundation for staff coaching and training.
Providing a systematic and scalable approach ensuring review criteria and results are accurate, reliable which reduces risk by identifying trends and potential issues of clinical staff performance, deficiencies, and errors.
Providing timely, standardized reporting as well as ad-hoc reporting capability improving internal evaluation, review efficacy and streamlining any external reporting mandate to demonstrate compliance quality program performance.