FAQ Directory: Utilization Management, Credentialing and Provider Network

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10.06.2016 Updated: Types of files included in the UM 4H file-review universe What types of files are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO)?

The following types of denials are included in file review for UM 4, Element H (UM 4F in UM-CR and MBHO):

  • Denials based on benefits that underwent a medical necessity review, which determined there was a benefit exclusion.
  • Denials based on failure to follow the organization’s reasonable filing procedures. (i.e., lack of timely filing, lack of prior authorization).
  • Auto-adjudicated claims denials or point of service (POS) claim denials that were not based on medical necessity (excluding duplicate claims).
  • Denials not listed above that are not based on medical necessity, such as reversals or prior decisions due to fraud or improper billing.

UM_CR 2016