Overview of AMM’s Utilization Management Program

AMM supports its UM process with a number of professional and quality-based resources that gives us an effective platform to make medical necessity and coverage determinations for our clients. During the past two decades, AMM has gained a reputation for offering both reliable and innovative UM programs.

AMM UM Service highlights include:

• Staffing
  • Round-the-clock, onsite staffing with UM nurses in the AMM call center;
  • Access to over 240 specialty physicians as part of AMM’s review panel covering the full range of clinical services and settings; and
  • Utilizing licensed and certified clinical personnel in all jurisdictions where AMM does business.
• Program Elements
  • A nationally known UM program that can be customized to meet client needs;
  • Facilitating precertification, concurrent, and retrospective reviews covering a wide range of settings and situations (e.g., the advantages of in-network versus out-of-network based upon a patient’s health care needs, the benefit package, and negotiated rates);
  • 24/7 UM coverage that can be “wrapped around” an existing program for night, weekend and holiday coverage;
  • Decisions based upon a number of factors at the same time including medical appropriateness, requested-setting, level of care, duration, and quality of care;
  • Use of evidence-based clinical criteria including InterQual guidelines;
  • Runs on an integrated health IT platform; and
  • Can be fully private-labeled.
• Regulatory Compliance/Quality
  • Continually maintaining URAC UM accreditation since 1992 (among several other program accreditations); and
  • Operations that are in full compliance with federal and state UM laws including the U.S. Department of Labor (DOL) standards.
• Online Access. Offering access through a secure web portal to:
  • Review a pending UM case in real time;
  • Review utilization data or report; and
  • Initiate a request for a precertification (to be implemented later this year).

AMM also brings to the table an integrated approach to UM decision-making. All of AMM medical management services are designed to be offered in a collaborative environment that promotes a seamless experience. This allows us to customize all AMM’s services including our UM, case management, disease management, nurse triage, prevention, readmission, and health information services to best meet client, patient and provider needs.

AMM promotes an interoperable health IT framework that connects and automates key workflows within the UM process. The round-the-clock staffing model helps ensure that patients do not fall through the cracks and that authorization can occur in a timely manner. This integrated approach helps standardize coverage decisions in a way that best serves the patient in light of benefits that are being offered.