Amy Kile

UM Intake and Determination SOP Document ID: UM 201 Approved By: Version: 1.0 Mary Jones, RN Clinical Manager Purpose To establish a standardized process for Utilization Management (UM) intake and determination to ensure timely, consistent, and compliant review of requests for healthcare services. Scope This SOP applies to all UM staff involved in the intake, review, and determination of authorization requests within the organization. Definitions • Utilization Management (UM): A process used to evaluate the medical necessity, appropriateness, and efficiency of healthcare services. • Intake: The initial receipt and logging of a request for service. • Determination: The decision made regarding the approval, denial, or need for additional information related to the request. Responsibilities • UM Intake Staff: Receive and log requests, verify completeness. • UM Reviewers: Conduct clinical review and make determinations. • UM Supervisors: Oversee process adherence and quality assurance. Procedure 1. Request Intake • • • • Receive request via phone, fax, electronic portal, or mail. Verify that all required information is present (patient details, provider info, service requested, clinical documentation). Log the request into the UM tracking system with date/time stamp. Assign the request to an appropriate UM reviewer based on service type and urgency. 2. Request Review and Determination • • • • Reviewer accesses the request and clinical documentation. Conduct medical necessity review according to established criteria and guidelines. If additional information is needed, contact the provider promptly and document the request. Make determination: • Approve: Request meets criteria. • Deny: Request does not meet criteria. • Pend: Awaiting additional information. 3. Communication of Determination • • • Document determination in the UM system. Notify the provider and patient (if applicable) of the determination within required timeframes. Generate determination notice . 4. Documentation and Record Keeping • • Ensure all actions, communications, and determinations are documented in the UM system. Maintain records in compliance with regulatory and organizational policies. Quality Assurance • Supervisors will conduct regular audits of intake and determination processes. • Monitor turnaround times and compliance with regulatory requirements. References Organizational Policies: • UM Policy ABC-0192 Federal Regulations: • 42 CFR Part 456 Subpart F – Utilization Review (UR) Plan requirements for Medicaid programs • 42 CFR 482.30 – Condition of Participation: Utilization Review for hospitals under Medicare/Medicaid • 42 CFR 438.210 – Coverage and Authorization of Services in Medicaid managed care • CMS Final Rule CMS-4201-F (2024) – Medicare Advantage and Part D Utilization Management requirements • 42 CFR 423.153 – Drug Utilization Management and Quality Assurance for Medicare Part D State Regulations: • NAIC Utilization Review and Benefit Determination Model Act – widely adopted or referenced by states for utilization review standards • Individual state-specific utilization management laws and administrative rules (varies by state; consult NAIC or state insurance department resources) Accreditation Standards (supporting best practices): • NCQA Utilization Management Accreditation Standards • URAC Health Utilization Management Accreditation Standards Revision History Date 2/6/2026 Revisions Initial Creation of SOP