Utilization Review Determinations Policy

The Utilization Review Determinations Policy provides a comprehensive framework for evaluating the medical necessity of healthcare services. It defines key concepts such as adverse benefit determinations, medically necessary services, and outlines the procedures for authorization and appeals. The policy aims to ensure timely and appropriate decisions regarding service authorizations while maintaining compliance with state regulations. Additionally, it emphasizes patient rights and protections during the review process. This document is crucial for maintaining quality care within the Utilization Management department.