utilization management

Advanced Medical Reviews (AMR) is an independent review organization founded in 2004 by two physicians. It provides physician-level peer review and utilization management services to health plans, group health organizations, PBMs, Medicare/Medicaid, and workers' compensation clients, backed by URAC accreditation since 2005 and HITRUST CSF certification.

365 days a year availabilitycustomizable review portal technologyindependent medical reviewpeer to peer reviewspecialty and state matching of physician reviewers

ALPS Services, Inc. (American Loss Prevention Services) is a Service-Disabled Veteran-Owned Small Business founded in 1987 that specializes in Medical Quality and Cost Control consulting. It provides comprehensive medical cost control services including utilization management, cost control, and quality assessment across all health care settings, and primarily works with prime contractors on state and federal contracts as well as health care insurers.

case managementclaims auditclaims processingcoding and DRG validationCost Controlmedical bill reviewmedical record abstractionmedical record reviewprovider credentialingquality assessmentsubrogation

AssureCare is a provider of integrated population health management software for healthcare and human services organizations, including payers, providers, pharmacies, and government healthcare programs. Headquartered in Cincinnati, Ohio, and part of the Vora Ventures portfolio, it offers a cloud-based Intelligent Care Platform and its flagship MedCompass platform that automates care management, streamlines workflows, and supports decision-making to improve patient outcomes and reduce costs.

AI innovationscare managementcloud-based platformData Analyticsintegration with enterprise systems and EHRsMedical billingmedical credentialing & enrollmentmedication therapy managementrevenue cycle management

Carelon is a healthcare services company that brings together clinical expertise, technology, and connected services to help make care more integrated, personalized, and sustainable. It serves healthcare payers, employers, governments, care providers, and life sciences companies, offering capabilities across pharmacy, behavioral health, medical benefits management, research, and healthcare operations.

analyticsbehavioral health servicesbusiness process automationcare navigationclaims processingclinical reviewcloud adoptionPharmacy Benefit Management

Care Agent BPO is a medical call center and healthcare BPO provider offering 24/7 telephone triage, answering services, and appointment scheduling for patients and healthcare providers. It provides highly trained overseas agents to U.S. companies for healthcare support, customer service, and back-office operations, with over 20 years of expertise and a focus on HIPAA compliance.

accounts receivable managementanalytics and business intelligenceanswering servicesappointment schedulingclaims and denial managementlead generation and sales assistanceMedical billingquality assurance and compliancerevenue cycle managementsoftware developmenttelephone triage

Cedar Gate Technologies, an IQVIA business, provides an end-to-end technology platform enabling payers, providers, and self-funded employers to thrive in value-based care. Its platform covers data management, analytics, care management, and payment administration, plus actuarial consulting and bundles program management services.

actuarial consultinganalyticsbundles adjudicationbundles program managementcapitation adjudicationcare managementclinical decision supportdata management

Eckman/Freeman & Associates is an innovative disability management company providing comprehensive medical cost containment for occupational and non-occupational illnesses and injuries. Founded in 1985 and headquartered in Lexington, Kentucky, it is a privately held woman-owned small business enterprise (WOSB) and URAC accredited in case management. Customers include workers' compensation, group health, long term disability, and auto/general liability carriers as well as employers and governmental entities.

case managementDisability managementMedical cost containmentVocational rehab

EdiPhy Advisors provides expert independent review and advisory services to healthcare stakeholders addressing complex regulatory, reimbursement, and dispute resolution matters. It is a URAC-accredited Independent Review Organization and a certified Independent Dispute Resolution Entity (IDRE) under the No Surprises Act, resolving payment disputes between healthcare providers and payers. For nearly three decades it has provided physician-led expertise across regulatory compliance, utilization management, revenue integrity, and independent dispute resolut

attorney-led arbitrationdenials management and appealsindependent dispute resolutionindependent review organization reviewsmedical necessity determinationsphysician advisoryPhysician ReviewRegulatory compliance supportrevenue integrity and coding consultation

Evernorth Health Services is a health services company that provides pharmacy, care, benefit and specialty services. It works with plans, providers and patients to address health care challenges around affordability, predictability and simplicity of care. Its services include pharmacy benefit services, pharmacy care, medical care, medical benefit services, behavioral care, and specialty services.

behavioral health carecare coordinationclinical programsfertility treatmentformulary managementhome deliveryhome infusionmedication managementpharmacist-led care programspharmacy benefit administrationpharmacy network servicesspecialty pharmaceutical distributionspecialty pharmacy integrationvalue-based programsvirtual care

Hindsait provides healthcare decision intelligence AI built on 12 years of healthcare-specific clinical NLP, with 100M+ medical records processed. Its platform supports prior authorization, utilization management, clinical review, payment integrity, risk adjustment, and population health workflows, and is live in production at WPS Health, a Medicare Administrative Contractor.

clinical NLPFHIR-native data lakehouseFWA detectionHCC codingHEDIS/Stars gap analyticsintelligent document processingon-premises or cloud deployment (GCP, AWS, Azure)predictive readmission modelsprior authorization automationrisk stratification

Since 1995 Humboldt IPA has partnered in delivering quality health care in Humboldt County. The Humboldt IPA provides leadership in working with health plans and health care providers to ensure that medical care is provided in a manner that enhances the public health and promotes access to quality care. Fostering local accountability while providing appropriate, proficient, cost effective medical care benefits the people of our community. Mission Statement: The Humboldt IPA’s mission is to provide our community with the highest quality of care in an efficient, cost-effective manner. We feel this mission is best accomplished by a local, physician-sponsored organization that understands the health care requirements of our community. We provide administrative, claims processing and medical management services for the following health plans: Anthem Blue Cross HMO Blue Lake Rancheria Medical.

care managementclaims processingcredentialingmedical managementreferrals