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FAQ Directory: Utilization Management, Credentialing and Provider Network

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5.20.2016 UM 4, Element H File Review and Medical Necessity Denials Are medical necessity denials included in the UM 4, Element H file review?

No. If an organization inadvertently includes a medical necessity denial in the UM 4H benefit denial file review, NCQA verifies that the file is appropriately classified as a medical necessity denial. If so, NCQA scores the file NA. If not, NCQA reviews the files under the benefit denial requirements of UM 4H.
 

UM_CR 2016