Group Health Services

Independent Medical Reviews

Group health insurance plans across the nation help millions of employees and their families stay healthy and productive. When plan coverage disputes arise, our clients rely on NEXUS to support their utilization management and appeals process effective, accurate independent medical reviews. We support all levels of review including Independent Peer Review, Pre-Certification, and Internal and External Appeals.

NEXUS group health services support our client’s group health plan management strategy by ensuring members receive quality care that is medically necessary and appropriately covered. Our solutions help plan sponsors successfully navigate the complex state and federal regulatory requirements with clinically-sound independent medical reviews.

The Clinical Experts
As one of the nation’s leading Independent Review Organizations (IRO), we support many of the largest group health plans in the country. Our clients rely on Nexus to deliver accurate reviews with speed and efficiency. Our physician panel and extensive expertise in the Group Health market differentiate Nexus and enable us to develop long lasting partnerships.

Our Group Health Services Include:

Internal/External Appeals
(Federal and State)
Experimental/Investigational
Medical Necessity Reviews
Quality of Care Review

Pre-Authorization
Specialty Pharmacy Carve-Out
Drug Regimen Reviews
Standard of Care Reviews

YOUR MODEL, OUR PLATFORM

NEXUS has designed clinically sound cost-containment solutions for seamless integration into any group health plan management model. We can tailor our platform to effectively align process, technology, and reporting for any unique workflow architecture.

Every aspect of our platform has been honed for efficiency, sustained by our state-of-the-art utilization review portal. Our physician portal was designed to optimize the reviewer’s expertise and reduce the administrative burden for all panelists and clients. Our customize client portal allows easy access real-time case information and determinations, rendering evidence-based decisions quickly and streamlined so your team can efficiently handle claims.When group health determinations flow quickly and accurately, members are delivered appropriate care they need.

STREAMLINE YOUR GROUP HEALTH PLAN APPEALS

Achieve both quality care and plan alignment with our group health services.