• Does the plan 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 plan review and revise criteria regularly?
• Can practitioners obtain the criteria upon request?
• Does the plan 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?

5.    Timeliness of UM (UM 5)

• Does the plan make decisions regarding coverage in a timely manner? Specifically, does it make preservice nonurgent decisions within 15 days; preservice urgent decisions within 72 hours; urgent concurrent decisions within 24 hours; and postservice decisions within 30 days?
• Does the plan notify members 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 plan gather sufficient information and consult with the treating physician?
• Does the plan assist with a member’s transition to other care when benefits end?

7.    Denial Notices (UM 7)

• Does the plan clearly communicate the reasons for denials of service?
• Can a practitioner discuss the reason for the denial with the plan’s physician reviewer?
• Does the plan state to the member and the practitioner its reasons for denial, in writing?
• Is the appeal process outlined clearly in all denial notifications?

8.    Policies for Appeals (UM 8)

• Does the plan have written policies and procedures for the resolution of member appeals?
• Does the plan have a process in place to respond to expedited appeals within three days?
• Do members have at least 180 days to appeal denial decisions?
• Does the plan have procedures for providing member access to all documents relevant to an appeal?
• Do members have 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 plan have procedures for allowing an authorized representative to act on behalf of a member?
• Does the plan have procedures for providing independent, external review of final determinations?
• Are members notified of further appeal rights?

9.    Appropriate Handling of Appeals (UM 9)

• Does the plan have a full and fair process for resolving member appeals?
• Does the plan follow the policies outlined in UM 8?

10.    Evaluation of New Technology (UM 10)

• Does the plan have a written description of the process it uses to determine whether or not it will cover new medical technologies or new applications of existing technologies, and has it implemented the process?

11.    Satisfaction with the UM Process (UM 11)

• Does the plan evaluate member and practitioner satisfaction with its process for determining coverage, and does it address areas of dissatisfaction?

12.    Emergency Services (UM 12)

• Does the plan cover emergency services without precertification in cases where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed?
• Does the plan cover emergency services if an authorized agent of the plan has approved the provision of emergency services?

13.    Procedures for Pharmaceutical Management (UM 13)

• Are the plan’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 plan restricts pharmacy benefits, does it have an exceptions policy for allowing?

14.    Triage and Referral for Behavioral Health Care (UM 14)

• Does the plan 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?

15.    Delegation of UM (UM 15)

• If the plan delegates decisions on approval or denial of coverage to a third party, is the decision-making process—including the responsibilities of the plan and the delegated party—clearly documented?
• Does the plan evaluate and approve the delegated party’s plan on a regular basis?