In accordance with the provisions of the member’s health plan, all
utilization review decisions are based on:
- the member’s health plan benefits;
- the AmeriHealth definition of medical necessity, including but not limited
to the most cost-effective setting for the requested services;
- the appropriateness of the requested care, services, and/or supplies;
and
- the member’s coverage at the time care, services, and/or supplies are
requested and provided.
Only licensed physicians may make denials of coverage of health care
services and/or supplies based on lack of medical necessity during a
utilization review.
The AmeriHealth physician medical directors and independent physician
medical consultants who perform utilization review services for AmeriHealth are
not compensated or given incentives based on their coverage decisions.
Contracted external physicians are compensated on a per-hour or
per-case-reviewed basis, regardless of the coverage determination. AmeriHealth
does not provide financial incentives to internal or external physicians
performing utilization review services for issuing denials of coverage.
Providers are required to enter all routine authorization requests through
the Authorizations transaction on the NaviNet® web portal
(NaviNet Open). If there are any requests that require immediate review or if
NaviNet Open is not available, please contact the Utilization Review department
at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey
or at 1-800-275-2583 for AmeriHealth Pennsylvania. Facilities
can also call these phone numbers for ambulance and discharge planning
needs.
NaviNet® is a registered
trademark of NantHealth.