2018 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] 

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


  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. Evaluation of New Technology (UM 10) 
  14. Procedures for Pharmaceutical Management (UM 11) 
  15. Triage and Referral for Behavioral Healthcare (UM 12) 
  16. Satisfaction With the UM Process (UM 13) 
  17. Delegation of UM (UM 14)   

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