In accordance with the benefits available under the member?s health plan and the AmeriHealth definition of medical necessity, it is our policy that all utilization review decisions are based on the appropriateness of care, services, supplies, and existence of coverage. Only licensed physicians who conduct utilization reviews may make denials of coverage of health care services and supplies based on lack of medical necessity.

The nurses, medical directors, other professional providers, and independent medical consultants who perform utilization review services for AmeriHealth are not compensated or given incentives based on their coverage decisions. Medical directors and nurses are salaried employees. Contracted external physicians and other professional consultants are compensated on a per-case-reviewed basis, regardless of the coverage determination. We do not reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals that would encourage utilization review decisions that result in denials or underutilization.

Providers are required to enter all routine requests for authorization through the NaviNet^? web portal. If there are any requests that require immediate review or if NaviNet is not available, please contact the Utilization Review department at 1-888-YOUR-AH1 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 NaviNet, Inc.