About

About National Medical Reviews NMR has conducted healthcare peer reviews and related services since 1996 and has been continuously URAC accredited as an Independent Review Organization since 2003. It presently holds a Certificate of Full Accreditation under URAC for compliance with the Independent Review Organization: Comprehensive Review (Internal & External) Accreditation Program. NMR receives over 100,000 reviews annually, including utilization reviews, disability, medical claim disputes, and billing dispute resolutions. Our review experience spans the continuum of care, including hospital inpatient and outpatient, behavioral health, home and community-based, ambulatory surgery centers, and long-term care. We also conduct review s addressing categories, such as medical necessity, experimental/investigational, disability verifications, administrative/contract, diagnosis-related group (DRG)/coding validations, billing accuracy, quality of care and fraud, waste & abuse. NMR has extensive experience in providing medical claim review services. NMR performs binding independent claim dispute resolution via state and federal agencies' contracts and/or certifications. NMR performs binding Independence External Appeal reviews for self-funded private industry business clients nationwide, pursuant to the Federal External Review Process under the Patient Protection and Affordable Care Act. Additionally, NMR is certified/contracted to perform these same binding independent External Appeals through state insurance and health departments as an IRO for the state. NMR was one of the first five companies to be certified as an Independent Dispute Resolution Entity by CMS and the Departments of Labor, Treasury and Health and Human Services to conduct billing dispute resolution reviews under the No Surprises Act. In addition to the contracts and scope of work listed above, NMR assists the Department of Justice, the Office of the Inspector General, and other clients on quality-of-care reviews. NMR’s goal is to assist our clients in improving the healthcare system by detecting potential Fraud, Waste, and Abuse. NMR utilizes the services of certified coders, case management, contract specialists, and/or clinical professionals to conduct these reviews, which may include Medical Necessity Documentation Review, Claim Bundling/Unbundling, Inpatient Stay Audits, Outpatient Facility Audits, CPT code validation, DRG Validation Services and Claims Reimbursement Analysis.