Utilization Management Accreditation Evaluation Options 

NCQA’s UM Accreditation program requirements assess key aspects of utilization management operations and focus on consumer protection and improvement in services. 

Key Assessment Areas (corresponding standards) 

  • Improving operations through an internal QI process (UMA 1) 
  • Ensuring appropriate agreements and collaboration with clients (UMA 2) 
  • Maintaining member confidentiality when conducting UM functions (UMA 3) 
  • Ensuring involvement of appropriate UM professionals (UM 4) 
  • Making fair and timely medical necessity decisions (UM 5) 

Standards 

  1. Internal Quality Improvement Process (UMA 1) 
  2. Agreement and Collaboration With Clients (UMA 2) 
  3. Privacy and Confidentiality (UMA 3) 
  4. Program Structure (UM 1) 
  5. Clinical Criteria for UM Decisions (UM 2) 
  6. Communication Services (UM 3) 
  7. Appropriate Professionals (UM 4) 
  8. Timeliness of UM Decisions (UM 5) 
  9. Clinical Information (UM 6) 
  10. Denial Notices (UM 7) 
  11. Policies for Appeals (UM 8) 
  12. Appropriate Handling of Appeals (UM 9) 
  13. Experience With the UM Process (UM 10) 
  14. Triage and Referral for Behavioral Healthcare (UM 11) 
  15. Delegation of UM (UM 12)

New Online Application Process

A new application and scheduling process begins May 15 for Accreditation programs.


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