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Independent Medical Reviews

KEPRO has been providing accurate, impartial and evidence-based medical reviews for commercial and public program clients since 1985. 

Contact KEPRO for Third Party Appeals You Can Trust. 

Members, payors and employers need an independent, trusted source to help resolve member disputes under the Affordable Care Act. KEPRO has been at that table since 1985. We are URAC accredited in health utilization management, ensuring that our processes meet all federal and state external review requirements. We are also licensed to perform review in all 27 states requiring such licensure. 

KEPRO is Up to Speed with New Regulations and Rules.

KEPRO’s program complies with all Affordable Care Act, Department of Labor, and State Department of Insurance requirements, as appropriate for health plans and employer groups. 

KEPRO’s program provides: 

  • Qualified operational staff and peer reviewers with an in depth knowledge of the IRO industry
  • Compliance with accrediting agency standards
  • Compliance with ERISA requirements
  • Quality management oversight
  • Turnaround times that comply with state and federal requirements
  • Credible, well documented review determinations
  • Processes that meet the needs and time frames of each client 

KEPRO has the Right Health care Professionals for Any Review.

KEPRO’s panel of more than 3,200 board-certified, actively practicing, specialty-matched reviewers and allied health professionals render medical necessity and experimental/investigational treatment determinations. Our reviewers must also have five years of post-licensure clinical experience and be in good standing in their communities. 

Our Reviewers Represent a Broad Range of Medical Specialties. 

Trained and credentialed to perform reviews and focus on appropriateness of diagnosis and treatment, they understand the current trends in their specialties. Specialists are recruited on the basis of their experience as independent clinical reviewers. Most reviewers are in active clinical practices. Many hold academic appointments. 

All KEPRO Reviewers Undergo a Rigorous Credentialing Process. 

Our reviewers are subject to primary verification of credentials and are re-credentialed every two years. We ensure the partiality of our reviewers, verifying that they have no conflict of interest or financial considerations before assigning them individual cases. 

How We Assign Reviewers. 

We assign independent reviews based on: 

  • Same/similar specialty, dictated by the medical condition, procedure, or requested treatment
  • State specific licensure requirements
  • No involvement in the initial review
  • No conflict of interest or financial affiliation with the member or the involved facility/provider 

Our Reviewers Apply Nationally Recognized Clinical Criteria. 

They utilize MCG® or InterQual® which can withstand legal scrutiny, and current clinical practice expertise to make evidence-based determinations. The reviewer may render a decision to uphold the denial, modify the determination, or reverse the original determination. 

We record the following information in the case and determination summary: 

  • Specific rationale, including why criteria were not met if the initial denial was upheld
  • Date(s) of service being denied
  • Date of the notice
  • State-specific requirements depending on if the patient is covered under a fully insured plan
  • Statement of KEPRO authority and responsibility to perform the review  

KEPRO Performs Reviews On Time, Every Time. 

It’s a commitment to service that made KEPRO the choice of thousands of organizations for almost three decades. And part of the holistic approach to health care management you won’t find anywhere else.

Find an Answer

Please describe KEPRO data security that ensures member information is protected.

As an organization that is charged with storing and transferring Protected Health Information (PHI), KEPRO is bound by HIPAA regulations, and is accustomed to managing the security and privacy of PHI. KEPRO currently exchanges data successfully and confidentially via secure encrypted means in support of all of our federal, state, and local government programs, and with commercial clients.

KEPRO has been implementing and supporting systems that require medical record, data security, and transmission for more than a quarter of a century, and has always placed primary importance on using systems that allow for fast and efficient connectivity, while still providing the highest level of data and system security. Our proven internal and external policies and protocols ensure compliance with state and federal laws and regulations, as well as any additional security measures you may require.

We have a stringent KEPRO Comprehensive Confidentiality Plan that governs our processes. KEPRO’s Privacy Officer, Security Officer, and the Compliance Officer have ultimate responsibility for oversight of the processes and procedures contained in the KEPRO Comprehensive Confidentiality Plan.

KEPRO's system is secure. Our information systems are secured by an in-depth strategy that utilizes multiple layers of operational, management, and technical controls to protect KEPRO assets. We also employ software programs designed to prevent unauthorized use by staff or outside entities.

All KEPRO information systems employ common security controls such as Firewalls, Anti-virus, Role Based Access, FIPS 140-2 Encryption for mobile devices, and the requirement of strong passwords. Information system users are assigned a security role based upon access requirements relevant to their positions and information/program privileges.

The HIPAA Security Rule requires entities to implement information systems that control access to healthcare and related systems. KEPRO adopts a subset of NIST 800-53 Rev 3 Security controls to maintain compliance with HIPAA. Based on these security standards, KEPRO mitigates risk to its Information system by focusing on such controls as:

  • Log-In Security. HIPAA security requires the use of secure User IDs and the use of passwords. KEPRO requires multiple account authentication processes within its information systems to verify the identities of our end-users. KEPRO's policy requires strong passwords that are changed frequently.
  • Access Control. HIPAA requires one of the following: Context Based Access, Role Based Access, or User Based Access. User Based Access is part of the Log-In Security component. KEPRO's Role Based Access gives individual users access relevant to their function in the organization.
  • Audit Trail. HIPAA requires the use of an audit trail to identify who accesses PHI. KEPRO systems track those who change the patient record, the date and time the record was modified, and the specific information changed. The system includes a read only audit trail that captures each time a system user views a case.
  • Session Time-out. KEPRO information systems account for session inactivity by locking screens after 10 minutes of inactivity.
  • KEPRO's physical space is secure. KEPRO’s computer, telephone, and hardware systems are located in climate controlled rooms with fire-suppression and electronic locking system. We allow only authorized access to the room.
  • KEPRO focuses training on confidentiality and security issues. All KEPRO employees undergo rigorous training on security and confidentiality of PHI. We have successfully provided this training to all staff regardless of their respective roles/duties.

KEPRO Headquarters

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777 East Park Drive, Harrisburg, PA 17111
Toll-free: 800.222.0771
Phone: 717.564.8288
Fax: 717.564.3862