3rd Level Review (Appeal) Purpose: Used if the 2nd Level review’s decision is Denial, giving the treatment provider one final opportunity to present the rationale behind the treatment request Scope: This decision is final. Several decisions can be rendered by the peer physician: Approval: The treatment provider can pursue the requested regimen Modified with Agreement: The peer physician recommends a modification to the requested treatment regimen and the treatment provider agreed to implement as modified Denial: The requested regimen is not approved for clinical reasons (not medically necessary or reasonable) Reviewer: A specialty-matched peer physician (Orthopedist to Orthopedist, Pain Management Specialist to Pain Management Specialist, etc.) Inputs: Referral form that outlines the request Medical records pertinent to the requested treatment Output from the 1st and 2nd Level review Clinical experience of the peer physician Evidence Based Medicine (sometimes defined by the Jurisdiction) Discussion: Unless otherwise stipulated by the customer or statute, the treatment provider is contacted and receives a copy of the report PRIUM Manages Compliance with the unique requirements for each jurisdiction, including time service The Utilization Review Accreditation Committee (URAC) model that is generally accepted as best practices Any special requirements from the customer Accreditation and licensing of reviewing physicians Appropriate assignment per Jurisdictional and UM requirements