A disciplined review framework
UM Physician Advisors LLC approaches utilization management as a clinical and operational discipline. The applicable framework can differ by payer, product, jurisdiction, benefit and service, so each review begins by identifying the standards that govern the case.
Quality principles
- Patient-specific review of the submitted clinical record
- Application of applicable coverage requirements and client-approved criteria
- Clear, concise rationale supporting the physician determination
- Escalation of ambiguous or complex cases when appropriate
- Consistency with client policies, workflows and documentation standards
- Ongoing attention to reviewer consistency and quality feedback
Medicare Advantage awareness
For Medicare Advantage engagements, review workflows must account for current CMS requirements governing medical-necessity determinations, applicable Traditional Medicare coverage criteria, and the circumstances in which internal coverage criteria may be used. Client-specific implementation remains subject to the applicable contract, benefit and current CMS requirements.
Privacy and secure workflows
This public website is intended for business inquiries only. Protected health information should not be submitted through the general contact form. Case-specific information should be exchanged only through a secure workflow approved by the contracting organization.