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Utilization Management

 

 

As of December 31, 2024, this page is no longer updated.

 

Provider Pre-Cert Portal

 

ActiveHealth Management is a Private Review Agent that works on behalf of your health plan. A Private Review Agent is a company that reviews certain procedures and services for medical necessity that are included on your health plan’s precertification list or otherwise require Utilization Review/Management under your health plan. We do not offer or sell health benefit plans, pay benefit claims, or maintain the network(s) of providers that participate under your plan. Any benefits for which a member may be eligible are determined by their health plan.

For information about your health plan’s Utilization Management program, or the services that require Prior Authorization (or “pre-certification”), concurrent, or retrospective review, please refer to your benefit plan documents, visit your plan’s website, or call their Customer Service number. To see services that are usually recommended for pre-certification by our customers, click here.

Utilization Management program summary

The Utilization Management (UM) program services are designed to determine whether clinical guidelines/medical necessity criteria for coverage are met, including guidelines and criteria related to:

  • The location and level of care,
  • The appropriateness of the proposed treatment compared to UM criteria, and
  • The requested length of stay for the course of treatment.

UM services help determine whether certain procedures and services meet the clinical guidelines and medical necessity criteria for coverage under your health plan. UM services can also help identify members for Care Management programs that may be available under their health plan.

ActiveHealth Management is committed to treating your information with care and respect and managing our utilization review program in a manner which is compliant with applicable State and Federal laws.  ActiveHealth Management’s Utilization Review program is accredited by Utilization Review Accreditation Commission (URAC).

The review process

In most instances, the treating provider will be initiating this process. All review requests can be submitted to ActiveHealth Management by phone, fax, or mail. The member, the treating provider, or the facility rendering the services can call the number on the back of the insurance card to request a review by phone or to get the appropriate fax number as they vary by group. The mailing address and other ways you can submit a request for review are:

ActiveHealth ManagementPO Box 221138Chantilly, VA 20153-1138General clinical fax number: (866) 617.4900

Provider Electronic Pre-Cert Request Portal
 

Provider Portal

If you are a healthcare practitioner and would like to submit a pre-certification request electronically and do not have a registration number, please call us at (855) 233.7390. Once you have completed the registration process, you can submit an electronic request by clicking here.

If you need further assistance navigating the provider portal, view our a step-by-step training guide.

Provider Portal training guide

 

The Utilization Management process includes:
  • Collecting information about the member’s condition from the provider. The type of information collected will depend on what is being requested. Information collected may consist of: the specific treatment or procedure being requested, reasons for requesting the treatment to include signs and symptoms,  the provider’s progress notes, radiology or laboratory test results, estimated length of hospital stay (if applicable), and any treatments (and the results) the member has tried that are related to the request.
  • Reviewing the information provided against clinical criteria to make a determination of the medical necessity of services provided or requested.
  • Notifying all parties involved: the member (or the member’s designee), the treating provider, and the facility rendering the service of the outcome of the review.
  • Reviewing the member’s case for possible discharge planning and Care Management needs.

ActiveHealth Management does not discriminate on the basis of race, color, national origin, religion, disability, age, sex, gender identity, or sexual orientation in its Utilization Management determination process.

Types of reviews performed

  • Admission Review is the first review of a medical or surgical admission after the member has been admitted.
  • Biomarker Test Exceptions can be requested using the contact information above. These requests can occur during the initial review request or internal appeal.
  • Concurrent Review is the follow-up review that takes place during an inpatient hospital stay or outpatient treatment.
  • Pre-Event Review is the review of a medical or surgical admission or procedure in advance of the actual admission or procedure date. This is often called “pre-certification”.
  • Retrospective Review occurs when a review of services occurs after the service or treatment has occurred.  If information regarding a review request is received after the member was discharged, the review will also be considered retrospective.
  • Step Therapy Exceptions can be requested, using the contact information above, when the use of a covered medication is restricted through the use of a step therapy protocol. These requests can occur during the initial review request or internal appeal. Information that is usually requested for this type of review include(s) but is not limited to: contraindications, previous adverse reactions, how well the drugs that have been taken have worked, or positive therapeutic outcomes.

How long does the UM process take?

The length of time it takes to conduct a review may vary depending upon a member’s health plan. ActiveHealth Management follows the timeframes required by applicable law, as well as any other applicable requirements (for example, URAC or client-required timeframes).

We conduct reviews within the timeframes specified in your health insurance documents and as required by applicable law.

Clinical criteria used

We use evidence-based, peer reviewed, nationally recognized clinical review criteria, which include:

The guidelines listed above, or other nationally recognized guidelines, may be used. These guidelines are available to you upon request and free of charge. If an ActiveHealth Management Clinical Policy Guideline was used to review your service request, click the link above. If you need assistance locating a guideline, please call 1 (855) 231.3719. (For Utilization Management requests such as pre-certification, please call the number on the back of the member’s insurance card.)

For more information about CALOCUS, please visit the AACAP website.For more information about LOCUS, please visit the AACP website.

Providers and members of fully insured plans may be able to access MCG guidelines by logging on to:

ActiveHealth Management’s clinical criteria are reviewed on an annual basis, or as needed, and updates are made with input from independent physician consultants of the appropriate medical specialties when new technologies or evidence-based medicine indicate the need for revisions.

Peer-to-peer
Providers seeking a peer-to-peer conversation should call (800) 422.7711.

Appeals process

Appeals can be requested after a denial has been issued for a requested service. Appeals can be requested within 180 days after a denial letter is received.

Appeals are performed by health professionals who:

  • Hold an active, unrestricted license to practice medicine or a health profession in a state or territory of the United States;
  • Are board certified (if applicable) by either the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists;
  • Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate;
  • Are neither the individual who made the original non-certification (or subsequent appeal decision), nor the subordinate of such an individual;
  • Are located in a state or territory of the United States when conducting an appeal.

Standard Appeals are done for requests that are non-urgent, or for services/treatment that has already been provided, and can be requested in writing or verbally, depending on your plan. Unless state laws or other regulatory requirements make these different, the following describes the timeframe for us to complete a standard, internal appeal:

  • If the plan has one level of appeal, 30 days from request;
  • If the plan has two levels of appeal, 15 days from request.

Urgent (or “Expedited”) Appeals are reviewed quickly for urgent situations. An expedited appeal may be requested when a denial is issued regarding a request that is made before or during an ongoing service and the treating practitioner or provider believes the member’s condition warrants an Expedited Appeal to prevent an adverse effect to the member’s physical or mental health or ability to regain maximum functioning.  Expedited appeals can be requested verbally or in writing. Unless state laws or other regulatory requirements state otherwise, expedited, internal appeals are completed within hours from request.

The appeal levels and timeframes noted above may vary, depending on the plan you have.

In most instances, the member, treating provider, facility providing the service, or authorized representative can request an appeal. Who can request an appeal can vary based on the type of plan you have. The mailing address and fax number to submit a review request is:

ActiveHealth ManagementPO Box 221138Chantilly, VA 20153-1138
Phone: (800) 422.7711Fax: (855) 231.1218

External Reviews

External Reviews (also known as Independent Reviews) may be available after the internal appeal process has been completed. External Reviews can be requested within four months from the date that the final, internal appeal was completed and are sent to an Independent Review Organization (IRO) for review.  The IRO will choose a health care professional with the appropriate specialty to conduct the review. IRO reviewers have no professional, family, financial, or research affiliations with Active Health Management. Expedited and standard reviews are available, depending on the circumstance of the request.

ActiveHealth Management coordinates external reviews upon agreement with our clients and includes directions for the external review process in denial and appeal letters per the client’s, or state’s, direction. Many clients, or states, coordinate the external review or have their Third Party Administrator conduct the external reviews.  Please call us or your insurance carrier to find out how an External Review can be requested.

State-specific information

Please click the link below to see any state-specific information or forms.

http://www.activehealth.com/members-providers