Medical Review
Medical necessity reviews for services outside the utilization review process
Through the Medical Review process, American Health’s skilled registered nurses and panel of providers use multiple resources to assist payers in
dealing with difficult claims issues. Our Medical Review experts provide clinically driven recommendations of medical necessity to clients. Cases
benefit from review by a panel of physicians with a broad range of specialties. Evaluations are completed on a per-case basis, thus providing
additional savings to claims payers.
Medical Review can be used to determine appropriateness related to:
- Cosmetic surgery
- High-dollar injectable medications
- Services that may be experimental or investigational
- Predetermination or claims review
- 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
- Dental services
- Plan exclusions of non-covered services
Product Highlights
- Medical necessity recommendations on a retrospective or prospective basis for health services that are not reviewed 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
- Provides reviews for benefit plan exclusions
