Menu

FAQ Directory: Utilization Management, Credentialing and Provider Network

Filter Results
  • Save
  • Email
  • Print

You are viewing a single FAQ from your previous search. Clear Search

expand all

5.20.2016 UM 4, Element H File Review Does UM 4, Element H file review include benefit denials that resulted from the UM medical necessity review process?

Yes. If an organization inadvertently includes a benefit denial in the UM 4–UM 7 medical necessity denial file reviews, NCQA verifies that the file is appropriately classified as a benefit denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the medical necessity denial requirements of UM 4–UM 7.

UM_CR 2016