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IRO Case Detail Report

The external review process has your case reviewed by a third party unaffiliated with your insurer. The external review process is purely a document review process; once the independent review organization has reviewed your case, it will issue a final case synopsis letter detailing the outcome of your case.

This report details prior external review cases for which a final determination has been made. It is updated every quarter (March, June, September, December) with decisions by Independent Review Organizations (IROs). This report contains information on a rolling four-year basis.

The report can be downloaded in Excel format here.

Questions?

Oregon External Review Staff
Exreview.Ins@dcbs.oregon.gov
971-375-7065

Please note that every external review case is unique and an overturn for one case does not guarantee an overturn for another. Information on this page is for historical informational purposes only. The Division of Financial Regulation cannot provide guidance on specific cases and outcomes of pending/potential cases or cases currently under review.

“Cases Where Full Review Was Completed" in the General External Review Yearly Statistics table (below) only includes case outcomes of “Overturned Denial," “Partial Overturn," or “Upheld Denial." Other case outcomes (found in the full report) include “Ineligible," “Administrative Overturn," “Insurer Overturn," and “Withdrawn".


General External Review Yearly Statistics
YearCases Received
Cases Where Full Review Was CompletedOther Case Outcomes
Cases ReviewedInsurer Denial Overturned or Partially OverturnedInsurer Denial UpheldCases IneligibleCases Overturned by Insurer or Administrative OverturnCases Withdrawn
2020367 273 96 35% 177 65% 79 12 3
2021326 241 76 32% 165 68% 61 16 8
2022498 354 131 37% 223 63% 110 18 16
2023
499
352
128
36% 224
64% 115
8 24
2024*241
175
57
33%118
67%56
2
8
*2024 data up-to-date through June 30, 2024.

In rare instances, a case may need to be reassigned to a different IRO than the one to which it was initially assigned. Case numbers that were ultimately reassigned are not included in the list of Cases Reviewed.

Redacted Synopsis Reports are available to the public upon request. Please send an email with requested case numbers to Exreview.Ins@dcbs.oregon.gov

Information contained in the report includes:

  • External Review Case Number
  • Date Division Received External Review Request from Insurer
  • Insurer
  • Type of External Review Requested
  • IRO Company
  • Decision Date
  • Case Outcome
  • Case Category
  • Full Procedure/Service/Treatment Name

Detailed explanations of each column can be found on the “Field Definitions" tab of the Excel spreadsheet.