Utilization Management

Ensuring Appropriate Care while Maximizing Cost Savings

Arizona Foundation, in conjunction with American Health Holding, offers an URAC-accredited Utilization Management program designed to positively impact claims costs and provide savings to benefits plans. The highly-specialized team of doctors and nurses view the best patient outcomes as their goal while ensuring opportunities for cost savings are maximized.

Members benefit from having access to registered nurse reviewers, a board certified Medical Director, an internal panel of board certified practicing physician specialists, and an external panel of specialists. The clinical professionals providing Utilization Management services benchmark against Milliman’s Days/1000, Admits/1000, and Average Length of Stay criteria to certify treatments and to direct providers towards the most cost-effective, quality treatment available. Cases are continually monitored to assure quality and appropriateness of care, and we report all Never Events and Avoidable Hospital Conditions.

Service You Can Depend On
All admission evaluations and reviews are conducted by registered nurses who have at least 5–8 years of clinical experience or by board certified practicing physician reviewers. The review is supported by state-of-the-art proprietary software that facilitates all the steps in the utilization review process and automatically identifies cases appropriate for Case Management intervention.

Program Highlights

  • A comprehensive approach to ensure „„the quality and appropriateness of care while maximizing cost savings and avoiding preventable high-cost procedures and hospitalizations.
  • Facilitation of all steps in the „„utilization review process, from initial patient or provider contact, through criteria application, evaluation and recommendation.
  • Services guided by the Total Quality Management program, which sets the highest priority on timeliness, accuracy, quality of care, and cost-effectiveness.
  • Capability of network steerage.

To learn more about Arizona Foundation's Utilization Management program or AFMC’s Network Products and Services, call 800-624-4277 or e-mail.