If delegates that render medical necessity determinations do not have access to, manage, or handle UM request receipt dates or UM decision notification dates for any client—and no receipt or notification dates are stored in the delegates’ systems—then UM 12, Element C, factors 5–7 may be scored Not Applicable (NA), because the intent of these factors is to evaluate the integrity of receipt and notification dates.
If an organization retains sole responsibility for receiving UM requests, documenting receipt dates, and issuing UM decision notifications—and its delegates render medical necessity determinations only—then UM 12, Element C, factors 5–7 do not apply to those delegates.
Applicable standards:
- Health Plan Accreditation: UM 12, Element C
- Behavioral Health Accreditation: UM 11, Element C
- Utilization Management Accreditation: UM 8, Element C
