UM Standards & Guidelines
Utilization Management (UM)

1.    UM Structure (UM 1)

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

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

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

  • Do qualified licensed health professionals oversee all medical necessity decisions?
  • Does an appropriately licensed practitioner review any denial of care based on medical necessity?
  • Does the organization utilize the expertise of Board Certified Consultants in its program?
  • Does the organization assure that no one involved in the decision making process benefits from denying treatment? 
5.    Timeliness of UM Decisions (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 and practitioners of coverage decisions within required time frames?
6.    Clinical Information (UM 6)

  • When determining whether to approve or deny coverage based on medical necessity, does the plan gather necessary and relevant information and consult with the treating practitioner?
7.    Denial Notices (UM 7)

  • Does the plan clearly document as well as communicate the reasons for denials of service?
  • Can a practitioner discuss the reason for a denial with the plan’s physician or other designated reviewer?
  • Does the plan notify the member and the practitioner of the reason(s) for a 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 initial denial decisions?
  • Does the plan have procedures for providing members 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 their policies as outlined in UM 8?
  • Does the plan assure that overturned decisions are handled appropriately?
10.    Evaluation of New Technology (UM 10)

  • Does the plan have a written description of the process it uses to evaluate new technology?
  • How does the plan utilize its evaluation to determine whether or not it will cover new medical technologies or new applications of existing technologies?
11.    Satisfaction with the UM Process (UM 11)

  • Does the plan evaluate member and practitioner satisfaction with its process for Utilization Management, and does it address identified 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 approved the provision of emergency services?
13.    Procedures for Pharmaceutical Management (UM 13)

  • Are the plan’s procedures for drug coverage clearly documented?
  • Are all procedures reviewed and updated regularly?
  • Are practitioners, including pharmacists, involved in developing and updating procedures?
  • Is there a clear process in place for applying the procedures and assuring that practitioners are aware of them?
  • Do the procedures cover patient safety issues?
  • If the plan restricts pharmacy benefits, does it have an exceptions policy?
14.    Triage and Referral for Behavioral Health Care (UM 14)

  • Does the plan prioritize and make referrals for behavioral health care based on accepted definitions for the level of urgency and setting?
  • Are these decisions made by licensed practitioners or by qualified staff with appropriate supervision?
  • Is there appropriate clinical oversight of all triage and referral decisions?
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?



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