An Independent Review Organization (IRO) is the neutral third party that conducts external review of a denial after internal appeals are exhausted. Its decision binds the plan. Some states run their own external-review program; others default to the federal HHS-administered process, but in each case an independent reviewer decides.
What an IRO does
- Reviews adverse determinations involving medical judgment, and rescissions, independent of the plan.
- Issues a decision the plan must comply with.
- Is assigned through the state program or the federal process, depending on the state and plan type.
Frequently asked
Is the IRO decision binding?
Yes. Under the external-review framework, the plan must comply with the IRO's determination — which is what makes external review the strongest non-Medicare step.
Who assigns the IRO?
The state's external-review program in states that run their own, or the federal HHS-administered process (operated by MAXIMUS) where the federal process applies.
Primary sources: 45 CFR 147.136 (internal claims, appeals & external review). General information, not legal or medical advice — confirm against the governing rule for the plan type.
When the appeal has to be written, and cited
Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.