Independent Review

Many consumers may be entitled to an external review to resolve a dispute that involves medical issues with an insurance company. Typically, the external review is requested of an independent entity after the health plan’s internal process has been completed. CFMC has been a designated independent external review entity for the state of Colorado since 2001.

Key features of our program guarantee that a knowledgeable, clinical judgment will be made on each case:

• An established network of nearly 150 credentialed physician reviewers in every medical specialty to conduct peer review
• Our annual requirements for recredentialing exceed our own quality improvement organization requirements
• Our automated, physician reviewer selection process ensures a match of a “like” physician reviewer to the physician provider
• Our internal quality control process guarantees that our physician and non-physician reviewers provide evidence based, unbiased review of the case under appeal
• Our external review services are tailored to the specific needs and time frames of our clients

CFMC identifies three areas that are considered in an external review:

• Medical Necessity—health care services or products that a physician or health care practitioner would provide to a patient in order to prevent, diagnose, or treat an illness, injury or disease
• Experimental/Investigational—the treatment is determined to be scientifically unproven by insurance company standards
• Medical Diagnosis, Care or Treatment

Contact Nancy Borgstadt, Director of Review Services at 800.950.8250 ext. 3153 or email Nancy at nborgstadt@cfmc.org.