American Health Holding

What American Health Holding does

American Health Holding, Inc. is a URAC-accredited medical management services company founded in 1993 in Worthington, Ohio by Ivan Gilbert, MD and Michael Reidelbach, currently headquartered at 7400 West Campus Road, Suite 300 in New Albany, Ohio. The company delivers Utilization Management, Case Management, and Disease Management programs on an integrated basis to third-party administrators, self-insured employers, Taft-Hartley and union health and welfare funds, health insurance carriers, managed care organizations, reinsurance carriers and managing general underwriters, and state and local government entities, serving roughly 3.1 million to over 5 million lives across all 50 states plus the Caribbean and Bermuda. Its portfolio extends well beyond the three URAC-accredited cores into specialized case management for maternity, neonatal/pediatric, oncology, transplant, chronic kidney disease, bariatric, and specialty pharmacy advocacy, supplemented by wellness, population health management, integrated behavioral health, 24/7 physician consultations, a 24/7 nurse line, medical transportation, medical disclosure for stop-loss/MGU clients, and medical cost containment services.

The technology backbone is iSuite, a proprietary web-based medical management system with browser-based access, role-based security, HIPAA and HITECH compliance, and 834 transaction set support, integrated across UM, CM, and DM workflows. The iSuite EZ Reports module provides scheduled and on-demand reporting with client- and group-level drill-down and search. Clinical decision-making is supported by MCG Health criteria (formerly Milliman Care Guidelines) for utilization review, and Disease Management enrollment is driven by an internally described advanced predictive modeling system paired with Insignia Health's Patient Activation Measure. Reported 2024 operational metrics include 550,000+ UM cases reviewed, 56,906 total cases managed, an average UM ROI of 8.2:1, an average Case Management ROI of 5.2:1, a Transplant ROI of 18.3:1, a Maternity Case Management ROI of 8.0:1, $7,401 average annual claim cost reduction per Disease Management member, and 28% average medical cost containment savings. The company is privately held and has operated as a subsidiary of CVS Health (NYSE:CVS) since CVS Health's December 2018 acquisition of Aetna, which had itself acquired Prodigy Health Group (American Health's parent since April 2006) in June 2011.

Revenue is generated through managed services contracts with health plans, employers, TPAs, MGUs, and public-sector entities, with pricing described as quote-based and tailored to client needs and plan size rather than as published tiers. Distribution is via direct enterprise sales organized around three regional Vice Presidents of Sales covering West/Southwest, Northeast/Mid-Atlantic, and Midwest/Southeast territories, supported by named account executives and biennial client satisfaction surveys administered by Saperstein Associates. The customer base is horizontal and distributed across named logos including International Benefits Administrators LLC, American National Insurance, New Era Life, Swiss Re, USI Southwest, Benefit Plan Administrators, MEBA Benefit Plans, and MEBA Benefit Plans, with over 75,000 Taft-Hartley members served and a stated 91% client retention rate. More than two-thirds of AHH's 251-500 employees work remotely, supporting nationwide delivery and the Bermuda/Caribbean extension.

Name

American Health Holding

Legal name

American Health Holding, Inc.

Website

https://americanhealthholding.com

Company type

Private

Founded year

1993

Operating status

Operating

Headcount range

251–500 employees

Short description

American Health Holding is a URAC-accredited medical management services provider delivering integrated Utilization Management, Case Management, and Disease Management through its proprietary iSuite platform to TPAs, self-insured employers, Taft-Hartley plans, insurance carriers, and government entities across all 50 states, operating as a subsidiary of CVS Health.

Ownership category

akta.pro rank

Product category

Medical Management Services

NAICS

Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292)

SIC

Services-Health Services (8000), Services-Misc Health & Allied Services, Nec (8090), Hospital & Medical Service Plans (6324)

akta.pro primary industry

Utilization Management (Prior Auth/Medical Necessity) Administration (HLAEALAF)

akta.pro secondary industry

Care Management & Population Health Program Administration (HLAEALAG)

Keywords

• Utilization management services
• Case management services
• Disease management programs
• Medical cost containment
• Health plan management

Headquarters

HQ city

New Albany

HQ country

United States

HQ region

North America

Offices2 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Marketing or Sales, Infrastructure, Others

Revenue model

1. Medical Management Services: Integrated medical management services including Utilization Management, Case Management, and Disease Management provided to self-insured employers, TPAs, insurance carriers, and government entities. Services are customized to client needs and delivered through proprietary technology platform. Revenue generated through managed services contracts with health plans and employers.

Pricing tiers

Go-to-market motion2 records

Distribution channels1 record

Marketing channels4 records

Core offering

American Health Holding provides URAC-accredited integrated medical management services — including Utilization Management, Case Management, and Disease Management — delivered to TPAs, self-insured employers, insurance carriers, Taft-Hartley plans, and government entities through its proprietary iSuite web-based platform. The portfolio extends to specialty case management (maternity, oncology, transplant, neonatal/pediatric, CKD, bariatric), population health, wellness, behavioral health, medical transportation, 24/7 nurse and physician access, medical cost containment, and medical disclosure services, all configurable at the plan and group level.

Product overview

American Health Holding provides a comprehensive suite of medical management services integrated through its proprietary iSuite platform. The core offerings include URAC-accredited Utilization Management, Case Management, and Disease Management programs, supplemented by specialized case management services for maternity, neonatal/pediatric, oncology, transplant, and chronic kidney disease. The portfolio extends to wellness, population health management, medical transportation, behavioral health integration, and 24/7 access services (Physician Consultations and Nurse Line). The iSuite technology platform serves as the backbone, providing browser-based access to all integrated programs with HIPAA-compliant security, electronic reporting via iSuite EZ Reports, and system licensing options. American Health operates as a CVS Health subsidiary serving approximately 3.1 million lives across all 50 states, the Caribbean, and Bermuda.

Differentiator

Problem solved

Functional benefit

Brands

• iSuite: Proprietary web-based medical management software system
• iSuite EZ Reports

Products and services

• Utilization Management URAC-accredited medical necessity review program for both inpatient and outpatient procedures, ensuring members receive appropriate care while maximizing cost savings through registered nurse reviewers and board-certified medical directors.
• Case Management URAC-accredited services designed to improve quality of patient care while maximizing cost savings through registered nurses and licensed social workers who serve as advocates, facilitators, and educators.
• Disease Management URAC-accredited program targeting nine prevalent conditions (asthma, CKD, chronic pain, CAD, CHF, COPD, diabetes, hyperlipidemia, hypertension) using evidence-based guidelines, advanced predictive modeling, and the Patient Activation Measure assessment with dedicated nurse health coaches.
• Medical Cost Containment Multi-level review approach including preliminary prescreen review, out-of-network negotiations using reasonable and customary rates, and comprehensive line-by-line bill audits checking for unbundling, erroneous charges, and coding discrepancies; delivers an average of 28% savings to clients.
• Medical Transportation 24/7 coordination of domestic and international medical transports including emergency air ambulance, complex ground transport, medical escort, commercial travel assistance, and transplant patient transport.
• Medical Disclosure Claim risk evaluation and rehospitalization projection services for stop loss carriers, managing general underwriters, and third party administrators, providing clinical assessment and 12-month prognosis projections for high-dollar medical and pharmaceutical claims.
• Medical Review Medical necessity reviews for services outside the utilization review process, including cosmetic surgery, high-dollar injectables, experimental services, predetermination, and retrospective chart reviews.
• 24/7 Nurse Line Confidential health care triage and advice 24 hours a day, 365 days a year with registered nurses averaging over 10 years of clinical experience, available in English, Spanish, and other translated languages.
• 24/7 Physician Consultations Around-the-clock access to licensed, board-certified physicians for diagnoses, medical advice, treatment recommendations, and prescription medications, reducing unnecessary doctor, urgent care, and ER visits.
• Population Health Management Managing the continuum of high- and low-risk cases across an entire population using clinically proven behavioral assessment and modification tools with personalized coaching.
• Wellness Programs targeting healthy individuals and those at risk for chronic conditions, including a Wellness Portal with health risk assessments, biometric testing, and lifestyle coaching.
• Integrated Behavioral Health Combination of medical management and employee assistance program guiding members with mental health or substance abuse conditions to appropriate care modes and reducing outpatient MH/SA claims, delivered through partnership with CuraLinc Healthcare.
• Onsite Medical Management URAC-accredited utilization and case management services provided at client locations with designated account executives, field directors, best-practice guidelines, and HIPAA compliance.
• Independent External Review Third-level appeals administration and management of final medical necessity determinations by URAC-accredited Independent Review Organizations, ensuring PPACA compliance.
• iSuite Medical Management Software Proprietary web-based medical management system providing integrated, centralized management of Utilization Management, Case Management, and Disease Management with HIPAA/HITECH-compliant role-based security, encrypted connections, and licensing options for clients and groups with multiple plans.
• Pre-Admission and Post-Discharge Counseling Programs designed to avoid complications and address readmission rates by providing education to members admitted for inpatient procedures, with coaching calls before and after hospitalization (95.5% Pre-Admission and 96.0% Post-Discharge participants avoid readmission).
• Specialty Pharmacy Advocacy Care management and cost containment solutions for specialty drugs, including medical necessity review, member advocacy, steerage, and claims review with PBM coordination.
• Maternity Case Management Specialized support for high-risk pregnancies to reduce complications and lower high-cost claims, staffed by nurses averaging 20 years of maternity and neonatal experience (8.0:1 average ROI).
• Neonatal and Pediatric Case Management Management of intensive care needs for neonatal and pediatric cases with specialized nurses providing ongoing education, emotional support, and financial options guidance.
• Oncology Case Management Comprehensive oncology care management with a three-level review process for chemotherapy and radiation treatments, staffed by oncology case managers averaging over 10 years of experience.
• Oncology Care Integration Full-service oncology program managing risk from detection to transitional care, including utilization management, case management, clinical claim audit, negotiations, and reporting.
• Transplant Case Management Experienced transplant specialists managing complexities of transplant services including pre-transplant, transplant, and post-transplant phases with liaison services and discount negotiations (18.3:1 average ROI).
• CKD Case Management Chronic Kidney Disease case management for members facing gradual loss of kidney function, providing support for dialysis and transplant needs with staff averaging over 10 years of specialty experience.
• Bariatric Care Management Program reducing complications of bariatric surgery through medical necessity review, network verification, and six months of Disease Management pre-surgery plus 12 months Case Management post-surgery.

Quantifiable outcome

• 8.2 to 1 average Utilization Management ROI
• +8 more outcomes

Named customers14 records

Segments7 records

Ideal customer profiles6 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration3 records

AI capability2 records

Feature4 records

Partnerships

Three partnerships are on record, tiered core and minor.

• CuraLinc HealthcarecoreStrategic or Co-development PartnerStrategic partnership for behavioral health services. American Health aligns with CuraLinc Healthcare to serve clients in an integrated, seamless fashion for employee assistance programs and behavioral health counseling services.
• Saperstein AssociatesminorOthersIndependent consultant that administers American Health's biennial client satisfaction survey and NPS assessment.
• MCG HealthcoreTechnology or IntegrationProvides clinical criteria guidelines (formerly Milliman Care Guidelines) used in American Health's utilization review process for determining appropriate care and medical necessity.

Scale indicators15 records

Recent moves9 records

Expansion highlights6 records

Direct peers

• eviCore (Evernorth/Cigna): eviCore is one of the largest independent utilization management and specialty benefits management companies, providing prior authorization and medical necessity review for TPAs, health plans, and employers — directly comparable to AHH's UM core offering but at significantly larger scale and backed by Cigna/Evernorth.
• AIM Specialty Health (Elevance Health): AIM Specialty Health provides utilization management, clinical appropriateness review, and specialty health management for imaging, oncology, cardiology, and other services — a direct competitor to AHH's UM and specialty case management lines, owned by Elevance/Anthem with deep payer integration.
• Magellan Healthcare: Magellan (part of Centene) provides specialty health management including behavioral health, radiology, and oncology UM, and case management services — overlapping directly with AHH's specialty CM, behavioral health integration, and utilization management offerings.
• New Century Health: New Century Health specializes in oncology and cardiology utilization management and clinical pathway management — directly comparable to AHH's Oncology Care Integration, Oncology Case Management, and Cardiology-related Disease Management modules.
• HealthHelp: HealthHelp (a WNS company) provides specialty utilization management for radiology, cardiology, oncology, sleep, and musculoskeletal services — a focused UM peer comparable to AHH's specialty utilization review and prior authorization services.
• Telligen: Telligen provides utilization management, case management, population health, and quality improvement services for government, commercial, and Medicaid populations — directly comparable to AHH's UM/CM/DM offerings with similar government payer exposure.

Broad incumbents

• Optum Health (UnitedHealth Group): Optum Health operates one of the largest healthcare services and care management platforms in the US, including utilization management, disease management, and population health — a broad incumbent that competes with AHH across multiple product lines, particularly with payer-owned integration advantages.
• Change Healthcare (Optum): Change Healthcare provides revenue cycle management, payment integrity, and clinical decision support including utilization review technology — a broad incumbent peer overlapping with AHH's medical cost containment and clinical review workflows.

Regional players

• Health Management Associates / HMA: HMA operates as a managed care support organization providing utilization management, care coordination, and quality improvement primarily for state Medicaid and public sector programs — a comparable peer with overlapping service lines though stronger public sector focus than AHH.

Emerging players

• MedImpact Healthcare Systems: MedImpact is an independent PBM that has expanded into medical benefit management and clinical prior authorization services — comparable in offering specialty drug review, utilization management, and clinical decision support services to AHH's Specialty Pharmacy Advocacy and UM offerings.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat7 records

Key risks6 records

Key highlights7 records

Customer concentration

Compliance5 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles3 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about American Health Holding