Approvals for inpatient elective admissions are based on procedures that require an inpatient level of care. There are times when procedures are precertified but never performed due to various reasons. In such cases, AmeriHealth is responsible for assessing whether the inpatient admission is still medically appropriate. Therefore, we are required to confirm if the precertified procedures were actually performed, and if not, to validate the medical necessity of the admission.

If we are unable to confirm the procedures, the original authorization request will remain open and payment will not be made. The Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, which is available in the Current Publications section of AmeriHealth NaviNet^® Plan Central, is being updated to reflect this process.

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