Utilization Management

Medical necessity review of both inpatient and outpatient procedures

American Health’s URAC-accredited Utilization Management program provides medical necessity reviews that ensure members receive appropriate care while maximizing opportunities for cost savings. Members benefit from our program’s 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.

Our clinical professionals benchmark against MCG Health’s days per 1,000, admits per 1,000 and average length of stay criteria to certify treatments. Cases are continually monitored to ensure quality and appropriateness of care, and we report all never events and avoidable hospital conditions. All admission evaluations and reviews are conducted by registered nurses with an average of 10 or more years of clinical experience or by board certified physician reviewers. The review is supported by American Health’s state-of-the-art proprietary software, iSuite, that facilitates all steps in the utilization review process and automatically makes referrals to Case Management.

Click here to see our Utilization Management key statistics.

Product Highlights:

• Facilitation of all steps in the utilization review process, from initial provider or patient 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 verification 
• Capability of accepting and responding to prior authorization requests through electronic transmission
• Utilization Management reports benchmarked using MedInsight from Milliman, Inc.

Testimonials

• I have never been disappointed with American Health's level of customer service. I can't think of a single occasion where we've asked for something and not received it. We are also very appreciative of American Health's Utilization Management reports. They're very informative, concise, comprehensive and user friendly to both the administrators and the clinicians on staff.
  

  Libby Watkins
  Director of Health Benefits Management
  American National Insurance Co. Galveston, TX
• We have been using American Health Holding for many years. From the relationship with our account executive to the quality of service provided, American Health is a knowledgeable and reliable partner.
  Thomas R. Daniel
  Administrator
  New Orleans Employers - International Longshoremen's Association New Orleans, LA