In certain instances, AmeriHealth has delegated utilization review activities to entities with expertise in medical management of a certain membership population or type of benefits (such as mental health/substance abuse, diagnostic imaging, and outpatient radiation therapy). A formal delegation and oversight process is established in accordance with applicable law and with nationally recognized utilization review and quality assurance accreditation body standards. In such cases, the delegate’s utilization review criteria are generally adopted by AmeriHealth for use by the delegated entity.
AmeriHealth has delegated utilization review activities to:
- Carelon Medical Benefits Management (Carelon)
- eviCore healthcare (eviCore), a specialty benefit management company
- Magellan Healthcare, Inc. (Magellan)
The following resources are commonly used among all of the utilization management programs:
AmeriHealth has contracted with Carelon to perform preapproval/precertification for certain services for our managed care members. Services include:
- Cardiology Utilization Management Program
- Musculoskeletal Utilization Management Program
- Certain outpatient nonemergent diagnostic imaging services
- Sleep studies
>>More about Carelon
AmeriHealth has contracted with eviCore to manage preapproval/precertification requests for the following services:
- certain genetic/genomic tests for all members.
- nonemergent outpatient radiation therapy services for all members;
Note: Preapproval/precertification is not required when radiation therapy is rendered in the inpatient hospital setting.
>>More about eviCore
Utilization review activities for mental health/substance abuse services have been delegated by AmeriHealth to a contracted behavioral health management company, Magellan. This company administers the mental health and substance abuse benefits for the majority of our members.
>>More about Magellan
Magellan Healthcare, Inc. manages mental health and substance abuse benefits for most AmeriHealth members.