Thirty-nine states mandate external reviews of health plan coverage denials. About one-third of these states certify external review organizations (EROs) and restrict health plans to using an accredited ERO for such reviews.

As a certified appeal agent, MCMC’s Medical Care Ombudsman Program conducts external reviews for a growing number of states when such reviews are mandated by federal or state government or as a condition for National Committee on Quality Assurance accreditation.

We conduct state-mandated external reviews concerning health plan denials involving medical facts, including medical necessity issues, investigational/experimental treatments, and clinical trial participation, and denials involving administrative or contract matters. We are certified to conduct reviews in:

• Arizona

• Arkansas

• California

• Colorado

• Illinois

• Indiana

• Ohio

• New York

• Oklahoma

• Pennsylvania

In addition, we conduct external reviews in all states that require health plans to arrange them.

Beginning in July 2001, NCQA-accredited health plans have been required to provide external reviews of coverage denials based on medical necessity. The MCOP program offers external reviews to meet these NCQA requirements.

External Review Questions Often Addressed:

• Should the health plan cover the proposed treatment?

• Is the proposed treatment medically necessary?

• Is the requested therapy likely to be more beneficial for the enrollee than any available standard therapy?

For more information on MCOP's extensive services, please call 888-313-6267, 301-652-1818 or e-mail mcman@mcman.com.