Healthcare Review Services
The standard for trusted healthcare reviews.
Healthcare Services
Internal Appeals
Utilization Reviews
Long-Term Care Reviews
Preauthorization Reviews
Quality of Care Reviews
Workers’ Compensation Reviews
Independent reviews you can stand behind.
As a URAC-accredited Independent Review Organization (IRO), MMRO delivers impartial, evidence-based determinations at every stage of the appeals process.
We conduct Internal and External Appeals, Preauthorizations, Workers' Compensation, Long-Term Care, Quality of Care, and Utilization Reviews — drawing on our nationwide network of board-certified physician experts to ensure each decision is fair and clinically sound.
Our independence and clinical expertise give clients the confidence to move forward.
When a dispute moves beyond the plan's internal process, an External Review provides the impartial, independent decision required by federal and state regulations.
As a URAC-accredited IRO, MMRO conducts external reviews in full compliance with the Affordable Care Act, ERISA, and applicable state mandates, ensuring every determination meets the highest standards for independence and clinical rigor.
State and Federal External Appeals
Internal Appeals
When a member or provider disputes a coverage or claim decision, an internal appeal gives the health plan a structured opportunity to reconsider.
These reviews require careful evaluation of the original determination, the medical evidence on file, and any new information submitted by the member or provider.
MMRO provides an independent clinical perspective from a board-certified physician with relevant specialty expertise. We ensure each appeal is examined on its medical merits and measured against current evidence-based standards.
We ensure each appeal is examined on its medical merits and measured against current evidence-based standards.
Preauthorization Reviews
Preauthorization reviews determine whether a requested service, procedure, treatment, or medication is medically necessary before it is delivered.
These reviews protect members from unnecessary or inappropriate care, help plans manage utilization responsibly, and ensure that approved services align with evidence-based clinical guidelines.
MMRO's physician reviewers evaluate each request against nationally recognized clinical criteria, the member's medical history, and the specific provisions of the plan, providing timely determinations that support both quality care and efficient operations.
Utilization Reviews
Utilization reviews assess whether care is medically necessary, appropriate, and delivered in the right setting — and they can take place at any stage of the care journey.
MMRO offers prospective reviews (before care is delivered), concurrent reviews (while care is in progress, often during inpatient stays), and retrospective reviews (after care has been completed and a claim is submitted).
Each review is conducted by a board-certified physician using established clinical criteria such as MCG or InterQual, ensuring consistency, transparency, and defensibility across every determination.
Workers’ Compensation Reviews
Workers’ compensation cases sit at the intersection of clinical care, employment, and regulatory compliance — and each one demands a careful, impartial review.
MMRO's physician reviewers evaluate the full picture of a claim, including causation (whether the condition is work-related), medical necessity of proposed treatment, the appropriateness of ongoing care, expected recovery timelines, and the injured worker's readiness to return to duty.
Our reviews comply with the specific workers' compensation guidelines of each jurisdiction, including state-mandated treatment guidelines and utilization review requirements, so employers, carriers, and third-party administrators can act with confidence..
Long-Term Care Reviews
Long-term care reviews evaluate whether a member's condition warrants ongoing care services such as skilled nursing facility care, home health services, assisted living support, or custodial care.
These reviews require a nuanced understanding of functional status, cognitive ability, activities of daily living, and the medical necessity of the proposed level of care.
MMRO's physician reviewers assess each case against policy criteria, clinical guidelines, and the individual circumstances of the member, providing thorough determinations that support both responsible plan administration and compassionate care decisions.
Quality of Care Reviews
Quality of care reviews investigate concerns about the appropriateness, safety, or effectiveness of care that has already been delivered — whether raised by a member, provider, regulator, or the plan itself.
These reviews require impartial clinical evaluation of the care provided, including adherence to standards of practice, appropriateness of treatment decisions, and any adverse outcomes that may have resulted.
MMRO's board-certified physicians conduct each review with strict objectivity, examining medical records, treatment protocols, and relevant clinical guidelines to identify whether the care met accepted standards.
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