Appeals and Independent Medical Reviews

Simplified, objective, accurate reviews

We render fast, independent, accurate determinations through a combination of trained health professionals, optimized process and enhanced technologies that streamline the most complex review programs.

Resources and credentials to meet your needs

1 million

benefit appeals completed annually

2,000+

healthcare professionals contracted on our panel in the US

$1 billion

taxpayer savings per year attributed to IMR for the California Workers' Compensation program

Resolve benefit disputes with a nonjudicial approach

We offer government the expertise and capabilities to review and disposition appeals from virtually any government agency or government-sponsored service, including eligibility, health, disability, and workers’ compensation.

Fully-credentialed national panel

Our clients have access to more than 2,000 independent health care providers and reviewers representing every recognized medical specialty and major licensed practitioner categories.

We contract with medical directors, health attorneys, pharmacist-attorneys, nurse-attorneys, nurse professionals and podiatrist-attorneys.

Expert, scalable appeals model

As the largest provider of government-sponsored benefit appeals programs in the United States, MAXIMUS offers government the ability to handle massive scale in any program area that requires appeal support. Our business model features document digitization, case management systems and appeal operations support.

Solutions designed to streamline decisions

Our experts apply cutting-edge technologies with nearly three decades of independent review and quality assurance experience - enabling us to deliver proven solutions that simplify the most complex review processes. Our objective is ensuring the best possible outcomes for citizens and the government by rendering accurate decisions quickly.

Workers Compensation Appeals

Developed as part of California's efforts to reform and control medical care and indemnity benefit costs in the workers’ compensation system, our independent medical review (IMR) solution resolves disputes about the medical treatment of injured employees.  Individual cases are routed to an independent healthcare professional who is screened to ensure he or she has no conflict of interest with the parties in the case.  With the introduction of IMR, disputes are resolved in 2 weeks on average - down from nearly 12 months under the cumbersome court system it replaced.

15,000

cases processed per month for California's program

Medicare Appeals

Since 1989, the Centers for Medicare and Medicaid Services (CMS) have relied on us to provide Medicare beneficiaries and providers with independent, conflict-free appeal decisions of health insurance denials.  Today we receive more than 600,000 appeals claims a year for Medicare Parts A, C and D. 

QIO-like entity

We are a certified Quality Improvement Organization-like entity

Medicare Appeals

Expertise for your needs

Our appeals work extends to virtually any government service, including eligibility, health, disability and workers’ compensation. Our appeals work includes hundreds of thousands of appeals annually from the following contracts:

  • Medicare Qualified Independent Contractor (QIC) Program appeals processing for Medicare Parts A, C and D
  • Medical review of Medicare Part A and B claims for the Department of Health and Human Services (HHS), Office of the Inspector General
  • Independent medical review services for the California Division of Workers’ Compensation and Texas Workers’ Compensation program
  • Medicaid and Children’s Health Insurance Program (CHIP) eligibility
  • Peer review services for the U.S. Department of Veterans Affairs, Office of Medical-Legal Affairs
  • Federal external review process for health benefit appeals under the Affordable Care Act
Expertise for your needs