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Member & Provider Appeals

Member & Provider Appeals


member & provider appeals

For over 20 years, leading payers have been turning to AllMed to process their member and provider appeals, for medical, behavioral health, pharmacy benefits, disability and DME.

Every health plan, MCO or TPA has its own unique protocols when it comes to managing this process.  Some payers use internal physician advisors and Medical Directors for managing first and second-level appeals. However, with more pressure on payers to reduce costs, improve quality and demonstrate arms-length objectivity to their members and providers, they increasingly turn to companies like AllMed to manage these clinical decision-making processes. This allows you to focus on their core competencies while offloading clinical decision making to IROs like AllMed, who are better equipped to manage the rigorous task of physician specialist credentialing, performance management, quality oversight and scalability that is needed in today's hyper-competitive landscape.

AllMed's member and provider appeals cover the whole gamut, from first and second-level internal reviews, to state and federal external appeals. All reviews are conducted by board-certified specialists and sub-specialists who are in active practice. Each appeal review is performed in compliance with URAC, NCQA, CMS, state and federal regulations, which are subject to oversight and audit through our Quality and Compliance programs. All of our services are deployed through PeerPoint, AllMed's state-of-the-art medical review portal, which embeds healthcare intelligence and automation tools that produce the highest quality reviews at industry-leading turnaround times and costs.

But what really makes us different is our people. Our commitment to consistently exceeding our client's expectations through everything we do, is why AllMed's clients remain our loyal partners year-after-year. This is because of the special care we take to recruit the highest quality talent, train and grow them and engage them in our lean management system. As a values-based company that puts culture first, our employees care deeply about each member's health and about delivering the highest quality care.