As part of our ongoing effort to assure that claims for hospital services provided to AmeriHealth members are paid in keeping with the Hospital Agreement executed between your hospital(s) and AmeriHealth, we are implementing a change to our review of inpatient admissions. Effective immediately, requests for payment at the rate reflecting an inpatient admission for certain conditions will be subject to a secondary review by an AmeriHealth Medical Director after an initial review by AmeriHealth utilization review nurses.

Secondary reviews may be required for conditions that are often appropriately managed with observation as an outpatient so that inpatient admission is avoided. Many times, the need for inpatient admission is not clear upon presentation, and an initial workup and institution of treatment may warrant ongoing ambulatory care, avoiding the need for inpatient admissions. Examples of such conditions include, but are not limited to, the following:

• abdominal pain
• asthma
• chest pain
• dehydration
• syncope
• transient ischemic attack (TIA)

AmeriHealth utilization review nurses will review all clinical information presented and organize it to allow for application of the relevant criteria set by InterQual^®, a product of McKesson. The case will then be referred to an AmeriHealth Medical Director for final review and determination. Please note that claims for outpatient observation services do not require a utilization review determination as a prerequisite for payment. The Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers will be updated to reflect this new review process.

If you have any questions, please call 1-888-YOUR-AH1 for AmeriHealth New Jersey or 1-800-275-2583 for AmeriHealth Pennsylvania, and say Authorizations.