Medical Helpline

Medical Helpline's Registered Nurses and Advocates help patients obtain appropriate and quality care, while maintaining control over costs. Our services generate quantifiable improvements in care and savings to both the patient and health plan. Our highly-specialized team determines medical necessity, location of care and appropriateness of In and Outpatient Medical, Psychiatric and Substance Abuse admissions/procedures using clinical experience and health care standards.

Inpatient Utilization Management

Evaluates acute inpatient admissions and acute mental health and substance services using nationally recognized guidelines and criteria. This includes review of the appropriateness of treatment plans, length of stay and discharge plans on concurrent and/or retrospective basis.

Outpatient Utilization Management

Reviews and evaluates the use of outpatient health care services and procedures using MCG Care Guidelines and criteria.

Medical Necessity Reviews

Medical Necessity Reviews (MNR) are performed when the requested services fail to meet evidence based on medical standards during the authorization process. They may also be requested to assist TPA’s with claims determinations and adjudication. MNR’s may require review by independent board certified physicians of the same specialty for complex and costly treatment plans to determine medical necessity. Medical Necessity is substantiated and evidenced using nationally accepted guidelines and compendia based evidence for research.

High Cost Imaging

Our Imaging Cost Management Program achieves substantial savings with immediate access to over 3,000 centers nationally, providing a savings averaging 40-65%.

Pathology Review

Biopsies, colonoscopies, MRI, CAT and PET scan results are monitored to identify potential Case Management cases early and before costly treatment begins.