1. Is the basic utilization-management structure defined?
2. Is the utilization-management administrator identified? Are procedures regarding adverse decisions and payment over adverse decisions clearly defined?
3. In instances when utilization-management review is not delegated, are policies and procedures regarding record reviews and on-site reviews clearly defined? Are they reasonable from the standpoint of the provider?
4. Is the provider obligated to any additional reporting requirements in connection with utilization-management? If yes, how extensive? Is the payor willing to compensate for extraordinary requirements?
5. Are utilization-management requirements clearly discernible; for example, are they noted on the subscriber’s identification card? Are utilization-management categories properly defined, such as concurrent or emergency admission?
6. Can retrospective denials be imposed?
7. Are there any utilization-management penalty provisions? If yes, how extensive?
8. Is the utilization-management plan available for review?
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