Accreditation of Our Review Services

LEADING THE CLINICAL REVIEW INDUSTRY

The healthcare ecosystem is subject to an enormous number of regulations. When selecting a clinical review partner, the choice goes well beyond the reviews and reports – what about the quality behind the solution? NEXUS has a resolute commitment to quality; our technology platform and processes are designed to state-of-the-art specifications for review quality and security.

NEXUS strives for excellence across our corporate brands, including ProPeer Resources and Analytix Health, because clients trust our solutions for their claims and risk management programs. In addition to our independent clinical review and utilization management services, ProPeer Resources, LLC (ProPeer), a wholly-owned subsidiary of NEXUS, provides independent medical review services to insurance carriers and group health programs across the nation. To demonstrate our national leadership in clinical review, we pursue and maintain accreditation with industry-leading standards bodies.

ACHIEVING URAC ACCREDITATION

As experts in evidence-based measures and specifications, URAC has been the gold standard of accreditation for the healthcare industry since 1990. URAC’s mission is to promote continuous improvement in the quality and efficiency of healthcare management.

NEXUS maintains URAC accreditation in Workers’ Compensation Utilization Management. URAC evaluates many factors in granting this accreditation:

Employs drug utilization management mechanisms to address therapeutic appropriateness, over and underutilization, dosage, duration of treatment, duplication, drug allergies, and more,

Provides an independent, unbiased determination of medical necessity beginning with an initial clinical review, then moving to a peer clinical review if needed,

Is prepared to address any risk to patient safety, such as contraindicated treatments, adverse drug interactions, or inappropriate treatment, during the review process,

Adheres to time frames outlined in the standards for urgent and non-urgent review determinations,

Understands and adheres to applicable state and federal regulations for Workers’ Compensation programs.

ProPeer has achieved URAC accreditation as an Independent Review Organization: Comprehensive (Internal & External). Factors URAC evaluates for IRO’s Include:
  • Is up to date on all federal and state regulations, organizational processes, data security and internal operations
  • Works with appropriately licensed and credentialed peer reviewers who are current on the latest medical standards and technologies
  • Ensures consistency, efficiency and accuracy in internal and external review recommendations.
  • Is equipped to deliver three types of utilization review services: retrospective, concurrent, and prospective
  • Provides expertise in experimental and investigational reviews, and are current on the accepted standards of care
  • Has immediate access to physicians and allied healthcare practitioners who are at the vanguard of medical treatments and services
  • Features expansive review panels of hundreds to thousands of experts who can provide access to all recognized specialties and subspecialties
  • Provides advanced, ongoing education and training to ensure the use of reviewers who are knowledgeable about the most current peer-reviewed literature and evidence-based medicine
  • Adheres to standards and guidelines intended to avoid issues of conflict of interest
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ACHIEVING HITRUST CERTIFICATION

In 2018, ProPeer earned HITRUST Certification, an important milestone in assuring we meet rigorous healthcare cybersecurity regulations and protect sensitive private healthcare information. The HITRUST CSF is the most widely-adopted security framework for independent clinical review. It comprehends ISO, NIST, PCI, COBIT, and HIPAA to provide a complete set of security controls.

Attaining this esteemed information security certification positions ProPeer in an elite group of organizations worldwide and one of the first IROs in the nation to have successfully obtained certification status. HITRUST CSF Certified status indicates that ProPeer Resources has met the rigorous, industry-defined requirements and is appropriately managing risk. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the HITRUST CSF helps organizations address these challenges through a comprehensive and flexible framework of prescriptive and scalable security controls.

For more information on the HITRUST CSF, visit the HITRUST Alliance website.

REVIEW SOLUTIONS YOU CAN TRUST

Let us show you why clients across the nation trust our accredited solutions.