FAQ Directory: Utilization Management, Credentialing and Provider Network

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5.15.2022 Clarify scope for UM 12, Elements A and C What are the differences in scope for system controls at the factor level in UM 12, Elements A and C?

For UM 12, Elements A and C:

  • Factors 1–5 apply to receipt and notification dates, covered in UM 5 and UM 8–UM 9.
  • Factor 6 applies to all UM system data for managing denials and appeals (not only the dates specified in factors 1–5), covered in UM 4–UM 7 and UM 8–UM 9.
  • Factor 7 requires a monitoring process that covers compliance with all policies and procedures described in factors 1–6.

UM_CR 2022