AHA- Home

HEALTHCARE SOLUTIONS We are dedicated to providing our clients with access to quality, cost effective nationwide healthcare services.

PRIMARY PPO ACCESS

Comprehensive coverage because of the unique structure, with contracts for some of the best local and regional Networks, in addition to the entire First Health Network

Offered to a client's employees who live within 20 miles of a hospital and physicians in the AHA member network
AHA sells Primary PPO Access to fully insured and self insured health plans in the United States, with excellent coverage in all 50 States (the alliance includes over 5,000 hospitals and 500,000 physician and ancillary providers)
PPO Access includes contractual discounts for plan members in their home service area, which is essentially where they live and work
Offers comprehensive coverage because of the unique structure, with contracts from some of the best local and regional networks, in addition to the entire First Health Network

AHA-USA TRAVEL, WRAP, RECIPROCITY ACCESS

This program provides your eligible employees and dependents access to participating providers across the nation when they become ill or injured while traveling away from their home network service area.

The AHA-USA Reciprocity program was developed, at the request of our clients, to achieve two primary objectives:

To provide our clients and their eligible employees and dependents with the ability to access providers in other participating Preferred Provider Organizations (PPOs) when they become ill or injured while traveling outside their home service areas.

To maximize the opportunity for our clients to receive the benefit of the preferred rates and fees associated with our participating PPOs.

With AHA-USA, clients can:

provide “in-network” benefits to plan participants/insureds traveling outside of their local service area.*
Realize significant savings and reduce healthcare claims costs by reducing the number of claims processed as “out-of-network”
Increase client satisfaction by offering greater geographical coverage and reduced costs for obtaining needed medical services when traveling outside the local network.*

As the delivery and support of healthcare insurance benefits becomes more and more competitive, we are able to provide our participating clients with a competitive edge through our AHA-USA Reciprocity program. AHA-USA allows plan participants/insureds and their dependents to access healthcare providers nationwide when they are traveling, while still retaining preferred “in-network” rates and fees for services. participating PPOs also benefit by knowing that claims for services rendered are going to be paid at “in-network” benefit levels by the participating AHA-USA client.

Because AHA-USA can significantly reduce the number of “out-of-network” claims, you can realize significant savings on health and medical care services, which helps to reduce the overall costs to the benefit plan. In fact, AHA-USA’s preferred rates and fees are identical to those provided to PPO members, insuring that you receive the lowest possible rates for delivered services. In addition, our AHA-USA Reciprocity program can increase satisfaction among your plan participants/insureds, decrease out-of-network complaints and reduce out-of-pocket expenses through greater use of “in-network” providers.

The AHA-USA Reciprocity program includes thousands of hospitals and hundreds of thousands of physicians and other providers across the United States, offering you the opportunity to expand your available network coverage well beyond your established local service area. Such an expanded network also offers your plan participants/insureds the peace of mind they need when they are traveling, bolstering their image of – and confidence in – their healthcare plan.

AHA-USA is completely transaction-based, and is available to all types of payers for their entire book of business, regardless of whether the payer’s clients access our provider systems on a daily basis. It is simple and easy to implement and administer, and no program fees are assessed unless AHA-USA is able to apply preferred rates and fees to the claim.

* Coverage may not be available in all areas. To be eligible for “In-Network” benefits while outside the home service area, services and treatments must be obtained at a participating provider.

Benefit even more from AHA-USA's reciprocity program's simple implementation and administration

With AHA-USA, you benefit as much from the program’s cost-effective operation as your plan participants/insureds do. The program is easy to implement and administer, as we provide ample support to make sure your program runs smoothly from the very beginning.

Implementation

It’s simple to get started in the AHA-USA Reciprocity program. Simply execute the AHA-USA Reciprocity program agreement or addendum for existing clients, which indicates that all services delivered through participating PPOs must be paid at “in-network” levels. You must agree to meet certain provider and AHA payment requirements for participation in the program.

You must also provide a listing of all benefit plans that will participate in the program, including in-and-out-of-network benefits for each group, plan or employer that participates. A complete listing of all group names and numbers, plan names and numbers, as well as employer names and participant/insured eligibility information for each group/plan and employer must also be submitted. You also agree not to stack networks or discounts in relation to the AHA-USA Reciprocity program.

To access services, your plan participants/insureds can simply call us or access our Web site for the location of their nearest provider. All reciprocal claims are forwarded to us for repricing, and we act as the central control point for any and all reciprocal claims, relieving you of the burden of “out-of-area” claims identification.

Administration

To administer claims and coordinate the AHA-USA Reciprocity program, you (or your claims payers) must designate specific individuals to act as program coordinators. These individuals will be responsible for forwarding /receiving/adjudicating all reciprocal claims, and remittance and payment of all reciprocal claims and program fees.

AHA receives reciprocity claims from you, your payer, the AHA provider systems or directly from the provider. Once we record receipt of the claim and verify that you participate in the program and are in good standing, we will then apply the preferred rates and fees. At this point, we will forward the repriced claim to you or your claims payer for adjudication. The claim will include a statement indicating the gross savings obtained, as well as the amount that you or your payer owes us for the reciprocal pricing. Payment for services rendered is then forwarded directly from you or your claims payer to the provider. The percentage of Savings payment is forwarded directly to us.

Want more information about the AHA-USA reciprocity program?

Simply call us at 1-800-870-6252 for details.

FEE NEGOTIATION

Offered and used by members when an employee’s medical claim does not meet the criteria for either Primary PPO Access or Travel/Wrap/Reciprocity Coverage

Offered and used by members when an employees medical claim does not meet the criteria for either Primary PPO Access or Reciprocity Coverage
Even though members' claims typically are in network (on average over 90% of the time) there is a need for out of network claims to be submitted to fee negotiation where the Provider is called by a fee negotiation specialist to determine if a discount can still be negotiated on behalf of the member and the health plan

REPRICING SERVICES

Reprice claims for Member Networks across the US or provide medical claim repricing on a standalone basis for clients who need our service

We have developed one of the most sophisticated, comprehensive, and efficient claims repricing systems in the industry. Our claims repricing system was developed in a modular fashion, which allows us to easily adapt the system to address any form of preferred pricing or fee schedule, from the simplest discount arrangement to the most complex hospital contract.

Our repricing software system utilizes ClarEDI certified ASC X12N 837 (005010) institutional and professional electronic transaction sets.

MAIL ROOM SERVICES

Streamline claim intake to provide a long-term, cost effective solution. Our focus is on helping organizations outsource their mailroom to achieve the results necessary to remain competitive in today’s market.

Often marketed as a standalone product where AHA contracts to perform medical claims for a client and/or Payer who is not contracted with AHA for any of the other products
AHA reprices claims for many of its Member Networks across the US
AHA also does medical claim repricing on a standalone basis for clients who need our service, usually small medical networks who need to outsource their repricing needs; in such instances, AHA can charge the client on a claim by claim basis, or on a per member per month basis

PROVIDER DATA SERVICES

Allows for capture and maintenance of extensive provider credentialing and demographic information—flexibility to capture as little or as much information as desired in regards to provider data

Due to the superior capabilities of our claims repricing system, we can provide you with more than 20 standard savings and utilization reports, provided free of charge on a quarterly basis, or on an ad-hoc basis using this web site. In the event you desire information not contained in the standard reports, custom reports are available for an additional fee.