Services

CORE BUSINESS

The core business of NMR is providing independent medical reviews for all types of benefit disputes and quality of care issues in both the medical management and workers’ compensation settings.

NMR services a diverse geographic coverage area and provides medical reviews on a nationwide scale. Our Peer Review Panel consists of Board-certified Physicians, Arbitrators, Certified Coders, Bill Review Specialists and Ancillary healthcare providers.

EXPEDIENT – UNBIASED – EXPERT OPINIONS

NMR provides expedient, unbiased, and expert opinions in a full range of utilization review services for both medical/surgical and behavioral health coverage addressing adverse determinations at the first, second and third level of review, as well as initial determinations.

EXCEED CLIENT EXPECTATATIONS

NMR’s Quality Management Program ensures that our clients receive the highest quality independent reviews from our peer reviewers in a timely manner. NMR employs a systematic procedure for continuously monitoring and evaluating our internal processes. This includes monitoring for quality in credentialing, medical management and medical director activities.

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QUESTION UNDER REVIEW

These reviews include issues pertaining to medical necessity, experimental / investigational, administrative, peer review on standard of care and quality of care concerns (for fraud, waste, and abuse).
IF YOU HAVE A QUESTION PERTAINING TO MEDICAL RECORDS – NATIONAL MEDICAL REVIEWS HAS THE ANSWER.

  • 1st, 2nd and 3rd Level Appeals
  • Alternative Dispute Resolution (ADR)
  • Coding and Claims Validation
  • Clinical Guideline Peer Review
  • Contract Reviews
  • Criteria Analysis
  • Diagnostic Resource Grouping (DRG)
  • Disability Determinations
  • Home Health Care (HHC) Audits
  • Independent Dispute Resolution Process (IDR)
  • Initial Claim Decisions
  • Long Term Care Benefit Trigger
  • Member Hearings via Teleconference and Videoconference
  • Medicare Exception and Reconsideration
  • Special Investigation Unit (SIU) Investigations
  • Workers Compensation Utilization Reviews

Patient Protection and Affordable Care Act (PPACA)

Client Testimonials

  • Appeals Specialist

    NMR goes above and beyond to deliver top quality work. I really value their time and effort they put into each case and appreciate their friendly staff reaching out to me with any questions or concerns. All my cases have been returned in a timely manner, which is of great importance to me.




    Appeals Specialist
  • Supervisor, Clinical Appeals Operations
    Our company’s experience with NMR has been nothing short of remarkable. NMR offers an extensive panel of Specialty Physicians, quick turn-around-times, and detailed, quality reports. NMR is our “go-to” for uncommon specialty reviews. They regularly meet or exceed deadlines, and with superior quality results. What’s also nice is, their portal is user friendly and can be personalized to meet business needs. Above all, NMR’s staff and support are exceptional! They are readily available and responsive to questions/comments in a timely fashion. NMR offers innovative solutions for associated business challenges, and they are very accommodating to unique processes. No ask is too big or too small! We truly value our business relationship with NMR and the exceptional service they provide!
    Supervisor, Clinical Appeals Operations
  • Manager Appeals and Grievances

    It has been amazing working with the NMR team. They are fully transparent in how they can help meet State and Federal requirements and always maintains an open line of communication. Exceptional customer service and a pleasure to work with. Highly recommend!




    Manager Appeals and Grievances

CERTIFICATIONS

National Medical Reviews is an Independent Internal and External Medical Review Organization with URAC Accreditation. National Medical Reviews is certified by the Departments of Health & Human Services, Treasury & Labor as an Independent Dispute Resolution Entity.

Since 1996 NMR has been serving:

ERISA Regulated Benefit Plans ♦ Federally Regulated Agencies ♦ HMO ♦ Health Care Facilities ♦ State Agencies ♦ Insurance Companies ♦ Medicaid ♦ Medicare ♦ PPO ♦ PBMs ♦ Self-funded Plans ♦ State Insurance Departments ♦ Third Party Administrators ♦ Utilization Management Companies ♦ Workers Compensation

Services
URAC Accreditation for National Medical Reviews Inc.