Every healthcare organization has different policies and procedures relating to the handling of healthcare appeals or appeals of adverse determinations. While state and federal regulations dictate in large part how these appeals are handled, each healthcare payer has much leeway in determining exactly how to deal with them. Many companies have first-level appeals or second-level appeals that are done inside their own organization and use the IRO as a third-level appeals entity. Other healthcare payers actually send all of their appeals directly out to IROs immediately as their first-level response. Some payers use the IRO