​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 HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth New Jersey) and AmeriHealth HMO, Inc. (AmeriHealth Pennsylvania) 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 should enter all routine authorization requests through the Authorization Submission transaction within PEAR Practice Management. Providers can call the Utilization Review department at 1-888-YOUR-AH1 (AmeriHealth New Jersey) or 1-800-275-2583 (AmeriHealth Pennsylvania) for requests that require immediate review or if the PEAR portal is not available.