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🔎 '''Independent review organization (IRO)''' is a third-party entity certified by a state regulatory authority to conduct external reviews of [[Definition:Insurance carrier | health insurance carrier]] decisions that deny, reduce, or terminate coverage for medical services based on [[Definition:Medical necessity | medical necessity]], appropriateness, or experimental/investigational status. The IRO system provides [[Definition:Policyholder | policyholders]] and patients with a binding, impartial appeal mechanism that operates outside the insurer's own internal [[Definition:Claims management | claims]] and appeals processes, and it has become a foundational element of [[Definition:Health insurance | health insurance]] consumer protection across the United States.

⚙️ After a member exhausts an insurer's internal appeals process — or qualifies for an expedited external review in urgent cases — the case is assigned to a certified IRO. The organization assembles clinical reviewers with expertise relevant to the specific medical condition and treatment at issue, who then evaluate the medical records, the insurer's rationale for denial, and applicable clinical guidelines. The IRO issues a determination that, in most states, is legally binding on the insurer: if the review overturns the denial, the carrier must authorize and pay for the service. Turnaround timelines are regulated, often requiring standard decisions within 45 days and expedited reviews within 72 hours for urgent situations.

📌 For health insurers, IRO overturn rates represent a meaningful performance indicator. Consistently high overturn rates may signal problems with the carrier's [[Definition:Utilization management | utilization management]] criteria, reviewer training, or clinical guideline alignment, and can attract regulatory attention during [[Definition:Market conduct examination | market conduct examinations]]. Conversely, carriers that maintain rigorous, evidence-based medical policies and clear documentation of denial rationale tend to see their decisions upheld more frequently. The [[Definition:No Surprises Act | No Surprises Act]] expanded the role of external review in certain surprise billing contexts, further increasing the volume and visibility of IRO activity. Managing the intersection of clinical integrity, [[Definition:Regulatory compliance | regulatory compliance]], and member experience around adverse benefit determinations remains one of the more complex operational challenges in health plan administration.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Utilization management]]
* [[Definition:Medical necessity]]
* [[Definition:Adverse benefit determination]]
* [[Definition:Health insurance]]
* [[Definition:No Surprises Act]]
* [[Definition:External review]]
{{Div col end}}

Definition:Independent review organization (IRO) - Revision history

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