URAC IRO Accreditation — Frequently Asked Questions

What is URAC Independent Review Organization (IRO) accreditation?

URAC IRO accreditation is a nationally recognized validation that an organization conducting third-party medical review meets URAC's standards for impartiality, reviewer qualifications, conflict-of-interest controls, clinical criteria application, and review timeliness. It applies to organizations conducting internal review (for health plans), external review (mandated by state or federal law), or both. Accreditation is awarded for a three-year period following a 10-to-12-month review process.

Who is required to obtain URAC IRO accreditation?

The Affordable Care Act (ACA) requires non-grandfathered health plans to use accredited IROs when conducting external review of adverse benefit determinations. Many state insurance departments independently require IRO accreditation as a condition of state registration. Federal and state managed care contracts increasingly specify URAC IRO accreditation as a qualification requirement. Organizations conducting No Surprises Act independent dispute resolution (IDR) may also be subject to accreditation requirements.

What types of organizations can apply for URAC IRO accreditation?

Any U.S.-based organization providing independent medical review services may apply, including:

• External IROs conducting adverse benefit determination reviews
• Internal review organizations working on behalf of health plans
• Comprehensive review organizations conducting both internal and external reviews
• Workers' compensation peer review organizations
• Independent dispute resolution (IDR) entities under the No Surprises Act
• Independent medical examination (IME) firms expanding into external review services

What are the core URAC IRO accreditation standards?

URAC's IRO standards (currently version 6.0 Comprehensive Review) assess organizations across several key domains:

• Reviewer qualifications and specialty access across all major physician specialties and subspecialties
• Organizational and reviewer-level conflict-of-interest controls
• Review timeframes for both standard and expedited determinations
• Evidence-based medical necessity criteria, applied consistently
• Appeals processes — documented and communicated to all parties
• Quality management programs with active performance tracking
• Record-keeping and documentation systems

Organizations providing both internal and external review must also meet disclosure requirements for internal review client relationships.

How long does the URAC IRO accreditation process take?

The accreditation process typically spans 10 to 12 months from application through award. The process includes four phases: (1) application completion, (2) desktop review of submitted documentation, (3) on-site review with organizational leadership and staff, and (4) URAC committee review and final determination. Once awarded, accreditation is valid for three years, with a mandatory mid-cycle monitoring validation review at approximately 18 months.

What happens during the URAC IRO on-site review?

During the on-site review, URAC's review team meets face-to-face with the organization's management and staff. Reviewers may conduct audits of operational processes, analyze personnel and reviewer credentialing files, review quality management programs, and evaluate how documented policies translate into actual practice. The on-site review is often where gaps between written policy and operational reality are identified. Thorough preparation — including mock interviews, document organization, and staff briefings — significantly improves outcomes.

What is the mid-cycle monitoring validation review?

The mid-cycle monitoring validation review is a mandatory URAC assessment conducted approximately 18 months into the three-year accreditation period. It ensures that accredited IROs remain in continued compliance with all standards, including reviewer qualifications, conflict-of-interest protocols, and record-keeping requirements. Organizations that achieve initial accreditation but allow compliance programs to lapse frequently encounter problems at the mid-cycle review. Maintaining an active, survey-ready compliance posture throughout the accreditation period is essential.

How much does URAC IRO accreditation cost?

URAC does not publicly publish its accreditation fees. Contact URAC directly for current fee schedules applicable to your organization type and review scope. IHS consulting fees for IRO accreditation support are scoped per engagement based on organizational complexity, the scope of services required, and whether the engagement covers initial accreditation, re-accreditation, or ongoing monitoring support. Contact IHS for a proposal.

What is the difference between internal review and external review accreditation?

Internal review refers to utilization review conducted on behalf of a health benefits plan — the IRO is working for the plan. External review refers to independent review of adverse benefit determinations, typically mandated by state law or the ACA, where the IRO operates independently of the plan. URAC offers separate accreditation tracks for internal-only, external-only, and comprehensive (both) review organizations. Organizations pursuing comprehensive accreditation face additional requirements, including disclosure obligations for internal review client relationships.

What are the most common reasons IROs fail or are delayed in URAC accreditation?

The most common causes of accreditation failure or delay include:

• Specialty coverage gaps — inability to document reviewer access across all required specialties
• Inadequate conflict-of-interest screening documentation
• Inability to demonstrate consistent timeframe compliance through operational data
• Policies that exist on paper but are not consistently followed in practice
• Inadequate preparation for the on-site review
• Standards version changes between initial accreditation and re-accreditation

Organizations that conduct a thorough pre-submission gap analysis avoid most of these problems.

Does URAC IRO accreditation cover No Surprises Act IDR entities?

Yes. URAC created a specific designation pathway for Independent Dispute Resolution (IDR) entities operating under the No Surprises Act. In 2023, URAC awarded its first IDR designation. Organizations seeking to operate as IDR entities should evaluate whether URAC's IRO accreditation or the IDR-specific designation is appropriate for their scope of services. IHS can assist organizations in determining the right accreditation pathway.

Can an organization hold URAC IRO accreditation alongside other URAC accreditations?

Yes. Many organizations hold multiple URAC accreditations simultaneously. IROs frequently also hold URAC Utilization Management (UM) accreditation, Case Management accreditation, or Workers' Compensation Utilization Management accreditation. URAC's standards are designed with complementary requirements across programs, and organizations pursuing multiple accreditations can often leverage shared policy infrastructure, quality management programs, and documentation systems.

How does IHS help organizations prepare for URAC IRO accreditation?

IHS provides end-to-end consulting support for URAC IRO accreditation, led by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC. Services include gap analysis, policy and procedure development, reviewer qualification program design, conflict-of-interest protocol build, desktop review document preparation, on-site review coaching, mid-cycle monitoring support, and full re-accreditation management. Engagements are scoped per organization — contact IHS for a proposal.

What makes URAC IRO accreditation different from state IRO registration?

State IRO registration and URAC accreditation are distinct but frequently interrelated. State registration is a regulatory requirement imposed by individual state insurance departments and varies significantly by state. URAC accreditation is a national, voluntary (though often mandated) quality credential issued by a private accrediting body. Many states accept or require URAC accreditation as evidence of qualification for state registration. Holding URAC accreditation typically streamlines multi-state registration by providing a recognized baseline of operational quality.

How often must URAC IRO accreditation be renewed?

URAC IRO accreditation is awarded for three years. Re-accreditation requires completing a full accreditation process — including application, desktop review, on-site review, and committee review — before the three-year period expires. The re-accreditation process typically begins 12 to 18 months before expiration to ensure continuity of accreditation status. Organizations that allow accreditation to lapse must restart the process from the beginning and may lose regulatory standing in states where accreditation is required.