Medical Review

Medical necessity reviews for services outside the utilization review process

Medical Review 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



  • American Health Holding has been a valued partner for over 12 years. We find them to be very helpful and responsive, especially working with their Case Management department.
    Patty Darrow
    RN, BSN, CCM

    Leggett & Platt Carthage, MO
  • American Health is easy to work with, very responsive and communicative. Their turnaround time is excellent. We are very satisfied, especially with the Medical Review staff.
    Edwin Embry
    Director of Benefits

    Cement Masons & Laborers Health & Welfare Fund Northern, CA
  • American Health's iSuite system provides the Wabash claim team quick and easy access to our members' precertification information. We utilize the system daily and find the convenience, ease of use and information a great asset to timely and accurate claim adjudication.
    Debby Kunze
    Medical Claim Manager

    Wabash Memorial Hospital Association Decatur, IL
  • American Health has provided Case Management and Utilization Review for Cerner HealthPlan Services since 2007. Case Management helps improve our members' experience through education, case oversight and identifying alternative care options when appropriate to maximize their health benefits. Utilization Review ensures oversight of inpatient and outpatient procedures for the most cost-effective, quality treatments to help realize health plan savings and appropriate health care services for our members. American Health plays a role in our ability to exceed our clients' expectation for benefits administration.
    Betty Safford
    Director, Client and Quality Operations

    Cerner HealthPlan Services, Cerner Corporation Kansas City, MO
  • I have been very impressed with American Health's client support. If one person is out I can call someone else who is always willing to assist. This is extremely helpful to our case management and medical review needs.
    Jeannie Couey

    BAS Limited Ridgeland, MS