AmeriHealth is dedicated to enhancing the health and well-being of the people and communities we serve. Our Quality Management Program regularly reviews the care and service our members receive and promotes clinical, network, and service quality through its activities. Examples include member safety and wellness initiatives, disseminating clinical practice guidelines and standards of care, collecting member feedback on their care, and investigating quality-of-care and service concerns. As a participating provider, you have agreed to cooperate with, participate in, and abide by the AmeriHealth Quality Management Program.

Standards of care

As a health care provider in our network, you are responsible for ensuring that our members receive quality care. Please review our standards of care in our Quality Management Program with your staff to confirm your office is meeting our standard of care requirements.

• Access and availability standards. To ensure our managed care networks meet the needs of our members, we provide standards for appointment access, the minimum number of office hours per practice per week, the maximum number of patients scheduled per hour per physician, and availability after hours. Our access and availability standards are in accordance with applicable regulatory requirements.
• Member rights and responsibilities. All AmeriHealth members have defined rights and responsibilities, including the right to be treated with respect, and the right to voice dissatisfaction about the quality of care or service they received to their health plan.
• Privacy and confidentiality. AmeriHealth, our contractors, and our affiliates are required to protect the privacy and confidentiality of our members’ personal and health information in accordance with applicable state and federal laws and regulations.
• Medical record keeping standards. Appropriate clinical documentation is fundamental to facilitating continuous and coordinated care. Medical records should be current, detailed, and organized as required by applicable regulatory requirements. We regularly review compliance with these standards and monitor the processes and procedures used to facilitate the delivery of effective and appropriate plans of care.
• Utilization review. Our utilization review process is intended to promote appropriate health care resource management and minimize clinically inappropriate interventions. Utilization review decisions are evidence-based and include a standardized review of the medical necessity of health care services and supplies related to the benefits available under the member’s coverage. We encourage peer-to-peer discussion by giving physicians direct access to AmeriHealth Medical Directors to discuss coverage decisions based on medical necessity. Additionally, clinical review criteria are available upon request.

Member safety and wellness initiatives

The following member safety and wellness initiatives aim to promote efficient utilization of services, facilitate coordination of care, promote adherence to the plan of care, and help to improve outcomes.

• Complex case management. Members with complex medical conditions like diabetes, asthma, high risk pregnancy, etc. may be eligible for case management programs. You can refer members online for AmeriHealth New Jersey or AmeriHealth Pennsylvania or by calling 1-800-313-8628.
• Drug Utilization Review. Targeted drug utilization reports are generated annually to identify opportunities for education related to prescribing and care coordination practices. Reports are sent via mail to your practice.
• Occurrence investigation. Our clinical staff, with Medical Director oversight, review all reported occurrences for quality issues. Our staff will request and review pertinent medical records, perform a detailed analysis, and request a corrective action plan from the facility or provider, if necessary. Please cooperate with all requests as outlined in your contract.

Learn more

For more information about our Quality Management Program, including our goals and activities, visit our website for AmeriHealth New Jersey or AmeriHealth Pennsylvania or call Customer Service at 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.

Information can also be found in the appropriate Provider Manual for Participating Professional Providers and/or the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers, which are available through the NaviNet^® web portal (NaviNet Open). Paper copies of the manuals can be ordered through our Office Administration/Patient Education Resources Order Form for AmeriHealth New Jersey or AmeriHealth Pennsylvania.

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