Independent Health Appeals

MAXIMUS is the national leader in providing independent appeals of denied health insurance claims. We pioneered this capability more than 20 years ago and have since completed approximately one million appeals, with a timeliness rate of 99% and agency evaluations of "excellent" to "outstanding."

We serve as the Qualified Independent Contractor (QIC) for Medicare Parts A, B (South), C, and D, as well as the administrative QIC (AdQIC). We also provide health appeal services to the U.S. Department of Defense TRICARE Program, the U.S. Office of Personnel Management, the Department of Veterans Affairs, and for more than 30 state health regulatory agencies.

Our experienced staff of medical professionals addresses health insurance disputes across all provider specialties and subspecialties regarding:

• Coverage
• Medical necessity
• Efficacy of new medical technology and experimental treatments
• Quality of care
• Payment disputes
• Health appeals for all levels of care from primary or emergency care to hospice

The Most Qualified Team of Experts

Only the most qualified and relevant experts make our appeal determinations. Our fully credentialed medical directors, physicians, pharmacists, therapists, nurses, and health attorneys are supported by our national panel of consulting practitioners. Collectively our team represents all medical specialties as designated by the American Board of Medical Specialties (ABMS) and all licensed allied health professions. We require and monitor documented use of appropriate evidence based criteria and scientific literature by our credentialed staff.

Dedicated to Protecting Patients' Rights

Through our work with the Centers for Medicare and Medicaid Services (CMS), we conduct work aimed at improving the efficiency and quality of services delivered to Medicare beneficiaries. All of our reviews are based upon objective clinical evidence and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations. We also use clinical protocols or practice guidelines developed by the health insurer (although the review organization is not bound by the insurer’s clinical protocols or practice guidelines), and all pertinent medical records, consulting physician’s reports and other information submitted by the parties.

Committed to Complete Independence

We were the first provider of this service to adopt a complete and comprehensive conflict of interest policy that severs any potential financial or management interests with the health industry. We do not manage, control, own or sell services to any health care practitioners, providers, health plans, or components of the pharmaceutical or device industry.