UM Standards and Guidelines

Utilization Management (UM)

1.    UM Structure (UM 1)

  • Does the organization have a written description of its program for managing care?
  • Is the program evaluated and approved annually?
  • Is a senior physician involved in the program’s operation?
  • Are behavioral health aspects described in the program description, and if so, is a behavioral health practitioner involved in them?
2.    Clinical Criteria for UM Decisions (UM 2)

  • Are criteria and procedures for approving and denying care clearly documented?
  • Are practitioners involved in procedures development?
  • Does the organization review and revise criteria regularly?
  • Can practitioners obtain the criteria upon request?
  • Does the organization evaluate the consistency with which the criteria are applied?
3.    Communication Services (UM 3)

  • Are UM staff accessible to practitioners and members to discuss UM issues?
4.    Appropriate Professionals (UM 4)

  • Do qualified health professionals oversee all review decisions?
  • Does an appropriate practitioner review any denial of care based on medical necessity?
  • Does the organization have written job description with qualification for practitioners that review denials of care based on medical necessity?
5.    Timeliness of UM (UM 5)

  • Does the organization make decisions regarding coverage within the time frames specified in NCQA’s standards and guidelines?
  • Does the organization notify members and practitioners of coverage decisions within the required time frames? 
6.    Clinical Information (UM 6)

  • When determining whether to approve or deny coverage based on medical necessity, does the organization gather relevant information and consult with the treating physician? 
  • Does the organization assist with a member’s transition to other care when benefits end?
7.    Denial Notices (UM 7)

  • Does the organization clearly communicate the reason for denial of service in writing to both the members and treating practitioners?
  • Does the organization provide the treating practitioner with the opportunity to discuss the reason for the denial with the organization’s appropriate practitioner reviewer?
  • Is the appeal process outlined clearly in all denial notifications?
8.    Policies for Appeals (UM 8)

  • Does the organization have written policies and procedures for the appropriate handling of preservice, post-service and expedited members’ appeals?
  • Does the organization have procedures for providing member access to all documents relevant to an appeal and provide members with the opportunity to submit comments, documents or other information relating to an appeal?
  • Are appeal reviewers disinterested parties (i.e., not involved in the initial denial decision)?
  • Are same-or-similar-specialty reviewers (i.e., practitioners in the same or a similar specialty who treat the condition under appeal) involved in appeals?
  • Does the organization have procedures for allowing an authorized representative to act on behalf of a member?
  • Are members notified of further appeal rights?
9.    Appropriate Handling of Appeals (UM 9)

  • Does the organization have a full and fair process for resolving member appeals?
  • Does the organization follow the policies outlined in UM 8?
10.    Satisfaction with the UM Process (UM 10)

  • Does the organization evaluate member and practitioner satisfaction with its process for determining coverage, and does it address areas of dissatisfaction?
11.    Emergency Services (UM 11)

  • Does the organization authorize emergency services without precertification in cases where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed?
  • Does the organization authorize emergency services if an authorized agent of the organization has approved the provision of emergency services?
12.    Procedures for Pharmaceutical Management (UM 12)

  • Are the organization’s procedures for drug coverage clearly documented, and is a clear process in place for applying the procedures?
  • Are all procedures reviewed and updated regularly?
  • Do the procedures cover patient safety issues?
  • Are practitioners, including pharmacists, involved in developing and updating procedures?
  • If the organization restricts pharmacy benefits, does it have an exceptions policy for allowing?
13.    Triage and Referral for Behavioral Health Care (UM 13)

  • Does the organization prioritize or make referrals for behavioral health care based on accepted definitions for the level of urgency and setting?
  • Depending on the case, are these decisions made by qualified staff or a behavioral health professional?
14.    Delegation of UM (UM 14)

  • If the organization delegates decisions on approval or denial of coverage to a third party, is the decision-making process—including the responsibilities of the organization and the delegated party—clearly documented?
  • Does the organization evaluate and approve the delegated party’s plan on a regular basis?
15.    Policies for Complaints and Appeals (UM 15)

  • Does the plan have written policies and procedures for the timely resolution of member complaints and appeals?


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