FAQ Directory: Health Plan Accreditation

Filter Results
  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.

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

expand all

5.15.2024 Use of AI for UM Decisions May organizations use artificial intelligence to make medical necessity denial decisions or appeal decisions?

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions. 

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.  

HP 2024