Utilization Management

Provides medical necessity reviews to positively impact claims costs

American Health's URAC-accredited Utilization Management program is designed to positively impact claims costs and provide savings to benefits plans. Our highly-specialized team of doctors and nurses view the best patient outcomes as their goal while ensuring opportunities for cost savings are maximized. Members benefit from having access to registered nurse reviewers, American Health's board certified Medical Director, an internal panel of board certified practicing physician specialists, and an external panel of specialists.

The clinical professionals providing American Health's Utilization Management services benchmark against Milliman's Days/1000, Admits/1000, and Average Length of Stay criteria to certify treatments and to direct providers towards the most cost-effective, quality treatment available. Cases are continually monitored to assure quality and appropriateness of care, and we report all Never Events and Avoidable Hospital Conditions.

Service You Can Depend On

All admission evaluations and reviews are conducted by registered nurses who have at least 5-8 years of clinical experience or by board certified practicing physician reviewers. The review is supported by American Health's state-of-the-art proprietary software that facilitates all the steps in the utilization review process and automatically identifies cases appropriate for Case Management intervention.

  • A comprehensive approach to ensure the quality and appropriateness of care while maximizing cost savings and avoiding preventable high-cost procedures and hospitalizations
  • Facilitation of all steps in the utilization review process, from initial patient or provider contact, through criteria application, evaluation and recommendation
  • Services guided by American Health's Total Quality Management program, which sets the highest priority on timeliness, accuracy, quality of care, and cost-effectiveness
  • Capability of network steerage

To learn more about American Health's Utilization Management program, please call us at (866) 614-4244 or send an email to marketing@AHHinc.com.