Utilization Management
Since 1989 AmeriBen Utilization Management, Inc. has focused on the needs of self-funded health plans and provided effective, proven and cost-efficient healthcare management services, including pre-certification and pre-determination of benefits, case management, and disease management. To better serve our clients, we have developed partnerships with reinsurers, providers, networks, and pharmacy benefit managers.
Pre-Certification/Utilization Review
Pre-certification and concurrent review use nationally recognized medical guidelines to determine the appropriateness of the medical treatment plan, the treatment setting and the length of stay. Sophisticated computer systems and software programs provide utilization history and allow steerage into network facilities.
In keeping with our appeals policy, participants are notified within 24 hours of an adverse decision and are informed that they or their authorized representative may request a review of our original determination. The request can be verbal or written but must be received within 180 days of the date on the denial notice. The participant or authorized representative may review pertinent documents/guidelines used in making our determinations.
Large Case Management
Working with our certified specialists - registered nurse case managers - can alleviate confusion as well as resolve concerns regarding medical care and coverage. Our case managers maintain direct contact with the patient, the employer, hospital, and ancillary providers.
Interaction with Stop Loss
Our nurses and certified case managers use a flexible information management system that supports collection and management of patient information, and retrieval and tracking of medical case and claims information. The integration of this data gives our specialists client-specific information, including enrollment and eligibility, medical benefits and exclusions, pre-certification requirements, network affiliations, and any special instructions they need to render determinations in a time sensitive manner.
It facilitates accuracy and consistency in quality of care coordination, collaboration, communication and reporting. Within 24 hours of confirming a patient’s diagnosis matches a diagnosis on the stop loss carrier’s trigger diagnosis list, a large case notification is sent to the client’s stop loss carrier.
Disease Management
Chronic medical conditions account for the majority of healthcare dollars and lost workdays. Our disease management programs prepare members to actively participate in the management of their disease.