Medical Review

Provides medical necessity review services to a claims payer on a retrospective or prospective basis outside of the traditional certification process

American Health provides medical necessity review services to claims payers on a retrospective or prospective basis for services outside of the traditional Utilization Management process. Through the Medical Review process, our skilled registered nurses and panel of providers use multiple resources to assist payers in dealing with difficult claims issues.

Recommendations You Can Trust

The experts providing American Health's Medical Reviews offer payers objective, clinically-driven recommendations of medical necessity. Cases benefit from being reviewed by a panel of physicians who have a broad range of specialties. Evaluations are completed on a per-case basis, thus providing additional savings to claims payers

Ensuring Appropriate Care

American Health's goal is to positively impact the process and outcome of patient care. Medical Review can be used to determine appropriateness related to:

• Cosmetic surgery
• High-dollar injectable medications
  
• Protocols, procedures, or medications that may be experimental or investigational
• Usual and customary fees
• Accuracy of coding
• Short- and long-term medical disability
• Purchase or rental of high-dollar Durable Medical Equipment
  
• Retrospective chart reviews
• Bill audits and dental services

• Medical necessity recommendation on a retrospective or prospective basis for health services that are not certified through the Utilization Management process
• Evaluations are conducted by a dedicated Medical Review team that includes a registered nurse and panel of board certified, practicing physicians
• Recommendations are supported by established medical guidelines
• Review for benefit plan exclusions

To learn more about American Health's Medical Review Program, please contact us by phone at 866.614.4244 or by Email at .