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Medical Management

Building healthy communities is the heart of everything we do.

We serve as advocates for our members by helping them successfully navigate the healthcare system to ensure they get the care they need. And we connect with providers to offer the resources needed to make smart decisions that improve patient outcomes.

AmeriHealth Caritas' comprehensive care programs effectively address the complex conditions encountered by the Medicaid and Medicare members we serve.  From maternity management and pediatric preventive care, to coordinated care for chronic, comorbid conditions, behavioral health services and pharmacy benefit management, our fully integrated care management (ICM) model drives both communication and care-plan development through a multidisciplinary management approach.   AmeriHealth Caritas' care programs have a successful track record of improving health outcomes and reducing preventable hospital admissions.

Care program components

  •  Integrated care management  
    • Complex Care Management
    • Episodic care management
    • Bright Start® (maternity management)
    • Pediatric preventive care
  • Behavioral services
  • Pharmacy benefit management (PBM)
  • Care Management/Rapid response
  • Quality management
  • Utilization management
  • Medication adherence

Integrated care management 

AmeriHealth Caritas' integrated care management (ICM) program uses a population-based health management program to provide comprehensive care management services. This fully integrated model allows members to move seamlessly from one component to another, depending on their unique needs. From this integrated solution, AmeriHealth Caritas delivers and coordinates care across all programs.

AmeriHealth Caritas's ICM team includes nurses, social workers, Care Connectors, clinical pharmacists, Plan medical directors, primary care providers (PCPs), specialists, members and caregivers, parents or guardians. This team works to meet our members’ needs at all levels in a proactive manner that is designed to maximize health outcomes.

Behavioral services through PerformCare®

PerformCare® specializes in providing superior, innovative solutions to support behavioral health, human services, and integrated health programs that are customized and outcomes-focused.

PerformRx - Pharmacy benefits management

PerformRx partners with plans through a clinical focus that is driven by real-time, proprietary technology and more complete integration of health and pharmacy data for better patient outcomes, more collaborative care and cost reductions that benefit all.

Care management/Rapid response and outreach teams

Our Care Management/Rapid Response and Outreach teams are designed to address the needs of members and to support providers and their staff. The team is composed of registered nurses, social workers and non-clinical Care Connectors. Together, this team provides the following services to our members and providers:

  • Provides health education via telephone.
  • Mails health education materials directly to our members.
  • Helps members interpret prescription instructions.
  • Helps our members understand medication side effects.
  • Provides prescription refill reminders.
  • Provides assistance overcoming transportation barriers.
  • Helps our members find resources for financial assistance when cost is an issue.
  • Provides information regarding available services and how to access them.

Utilization management

We are sensitive to the interruption that prior authorization (PA) can cause in a provider’s workflow. Our goal is to ensure that members and providers alike can easily understand and identify which services require PA. We will alert providers to changes in authorization requirements in a timely manner on AmeriHealth Caritas' individual health plan websites or individual outreach when necessary.

Medication Adherence

AmeriHealth Caritas has an enterprise-wide goal to increase our members' medication adherence. We are targeting our initiative to four classes of medications typically associated with chronic diseases:

  • Asthma controllers
  • Oral hypoglycemics
  • Antihypertensives
  • Statins

AmeriHealth Caritas has programs in place that can help providers identify members who might be struggling with medication adherence and offer solutions. Collaboration with our providers, as well as member outreach and education, are key components of this effort.

Care gap alerts with eligibility

An important component of our Medication Adherence initiative is the availability of Care Gap reports available through our robust provider portal. Pop-up alerts occur when checking member eligibility to remind providers that a member is at risk due to missing or overdue preventive services, or under-utilization or absence of disease-specific controller medications.