Utilization Management

Pre-Certification

Concurrent Review

Discharge Planning

The AHM Utilization Management program provides integrated services beyond the traditional "utilization review" model for approving the medical necessity of procedures, equipment, and services.

• Our processes are flexible, and customized to the employer's/purchaser's individual group benefit plan requirements
• All requests are reviewed to determine if the services meet established treatment guidelines and "best practice" standard of care
• The most cost effective alternate level of care is identified and coordinated when appropriate
• Services are channeled to network providers whenever possible
• AHM Coordinators assist the hospital discharge planners to coordinate the discharge plan and ensure that the providers and the proposed level of care are appropriate
• Cases are referred to Case Management to ensure smooth transition to outpatient care coordination
• Our Medical Directors serve as reviewers and clinical consultants to providers and staff

Medical Case Management

Through our A Step Above™ process that integrates various review functions, our clinical team indentifies members that are appropriate for case managment interventions. These members may have chronic diseases, episodes of acute illness, ongoing medical managment needs, require organ transplantation, or have sustained a catastrophic injury.

• The AHM Case Management/Disease Management process focuses on the health and well being of the whole patient
• Our RN Case Managers have extensive experience in many specialty areas of clinical practices, such as; organ transplantation, dialysis, cancer, high risk pregnancy, as well as managed care principles and practices
• AHM's Case Managers work closely with the clients and providers to ensure that each member recieves services that are appropriate, efficient and effective
• Each case is carefully managed to include ensuring that the care provided meets "standard of care" guidelines, the utilization of available alternative funding sources, and identification of available community resources
• AHM Case Managers provide valuable education and educational resources to patients and their families and/or caregivers
• Monthly clinical update and cost savings reports are provided to the client