/
/
Independent reviewer

Independent reviewer

An organization (sometimes called an Independent Review Entity or IRE) that has no connection to a Medicare health plan or Medicare Prescription Drug Plan. Medicare contracts with the IRE to review a case if a beneficiary appeals their plan’s payment or coverage decision or if the plan doesn’t make a timely appeals decision.

An organization (sometimes called an Independent Review Entity or IRE) that has no connection to a Medicare health plan or Medicare Prescription Drug Plan. Medicare contracts with the IRE to review a case if a beneficiary appeals their plan’s payment or coverage decision or if the plan doesn’t make a timely appeals decision.

  • Independent reviewers are healthcare professionals who are responsible for reviewing medical claims and making decisions about whether or not they should be covered by Medicare. They play a crucial role in the Medicare system, as they help to ensure that the medical treatment and services provided to beneficiaries are necessary, appropriate, and cost-effective.
  • One of the main benefits of Medicare independent reviewers is that they are not affiliated with any particular healthcare provider or medical facility. This means that they are able to make unbiased decisions about what should and should not be covered by Medicare.
  • There are several types of Medicare independent reviewers, including medical review nurses, medical review physicians, and an administrative law judge. The specific role of an independent reviewer will depend on the type of medical claim being reviewed and the individual’s area of expertise.
  • Medicare independent reviewers may be called upon to review a wide range of medical claims, including claims for hospital stays, outpatient procedures, DME, and more. They will consider factors such as the individual’s medical history, the proposed treatment or service, and the potential benefits and risks of the
    treatment or service.
  • To be eligible for review by a Medicare independent reviewer, an individual’s medical claim must meet certain criteria. For example, the claim must have been denied by Medicare, or the individual must have requested an appeal of the decision. In addition, the individual must have exhausted all other available avenues of appeal before turning to an independent reviewer.
  • Medicare independent reviewers are healthcare professionals who play a crucial role in the Medicare system by reviewing medical claims and making decisions about what should and should not be covered. They are able to provide unbiased decisions, ensuring that the medical treatment and services provided to beneficiaries are necessary, appropriate, and cost-effective.
  • Independent reviewers ensure fair adjudication of appeals, providing beneficiaries with an unbiased evaluation of their cases. Understanding their role empowers individuals to navigate the appeals process effectively, ensuring equitable treatment.

    Curious to learn more about the appeals process and the role of independent reviewers? Download our informative e-book for valuable insights and guidance on navigating Medicare appeals successfully.

    Get Personalized Medicare Guidance
    Navigating Medicare can be overwhelming. Our experts are here to provide personalized guidance tailored to your needs.
    Related Glossary
    ALS

    Think You Know Medicare?

    Take This Quiz to Prove It!