Active Health Management is a Private Review Agent that works on behalf of your health plan. A Private Review Agent is an entity that reviews certain procedures and services 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, maintain the network(s) of provider that participate under your plan, or determine your plan’s benefits. 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.
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 identity members for Care Management programs that may be available under their health plan.
ActiveHealth 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’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. Review requests can be submitted to Active Health 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 to submit a review request is:
Active Health Management
PO Box 221138
Chantilly, VA 20153-1138
The Utilization Management process includes:
- Collecting information about the member’s condition from the provider
- Reviewing the information 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
Types of Reviews Performed:
- 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”.
- Admission Review is the first review of a medical or surgical admission after the member has been admitted.
- Concurrent Review is the follow-up review that takes place during an inpatient hospital stay or outpatient treatment.
- 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.
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. Active Health 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:
- State or client-specific guidelines, if applicable
- Active Health Management clinical guidelines
- MCG® (formerly Milliman Care Guidelines)
Other nationally recognized guidelines may be used. These guidelines are available to you, upon request and free of charge, by calling: (855) 231.3719.
Active Health 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.
State Specific Information
Please click the link below to see any state-specific information or forms.