Medical Reviews
Provides medical necessity review services to a claims payor on a retrospective or prospective basis outside of the traditional certification process.
Through the Medical Review process, American Health’s skilled registered nurses and a panel of providers use multiple resources to assist the TPA in dealing with difficult claims issues.
The Medical Review process can be used to proactively or retrospectively address issues such as:
- Medical necessity determination
- Cosmetic surgery review
- Bundling and unbundling of coding
- Appropriateness of coding
- Benefit Plan compliance
- Review of high-dollar injectable medications
- Review of usual and customary fees
- Purchase or rental of high-dollar durable medical equipment
- Review of protocols, procedures or medications that may be experimental or investigational
- Non-covered benefits
Fast Facts
- Utilization of American Health’s experienced managed care team, including RNs, board-certified Medical Directors and panel of board-certified, practicing physician specialists
- When necessary, reviews can be sent to an external review organization comprised of physicians representing over 250 different specialties
- Most reviews are completed in under five days
- Competitive pricing—most reviews are done on a per-case basis
- Savings are realized in a majority of cases