MedHOK's Pharmacy External Review is a CMS-compliant workflow solution for processing and tracking IRE cases for Medicare and External Review cases for Medicaid and commercial lines of business. The system tracks and processes out-of-compliance cases and systematically routes them into the IRE/External Review workflow to be auto-forwarded to the IRE/External Review entity for processing. The IRE/External Review module facilitates outbound and inbound cases as well as member-requested reviews. The module allows for key data input and tracking of cases sent to the IRE/External Review entity as well as their decisions, documentation and associated effectuation dates. All IRE and External Review cases are linked to the original appeal to support quick, efficient review of information related to all aspects of the process.
The MedHOK Pharmacy External Review functionality (RxExRM) manages, tracks, and auto-forwards cases to an external review entity and manages and tracks appeals received from the external entity or from the ALJ, MAC, or for Judicial reviews. The solution assists plans in following the external review process and allows plans to document and process any level of external review.
Customers use the solution to: