Do utilization review (UR) policies and procedures need to be filed with the administrative director?

• A. Yes
• B. No
• C. Only if requested
• D. Only in the event of dispute

Answer: (A)

Utilization review (UR) policies and procedures must be filed with the administrative director to ensure compliance with regulatory standards and to provide transparency in the management of healthcare services. This requirement is rooted in the need for oversight and accountability in the determination of medical necessity and the appropriateness of care provided to patients.

Filing these policies allows the administrative director to review and ensure that the UR processes within a healthcare organization adhere to established guidelines and best practices. This step is crucial for maintaining quality control, mitigating risks, and ensuring that patients receive the care they need without unnecessary delays while also protecting the interests of the healthcare system.

The necessity of filing UR policies highlights their significance in promoting fair and consistent treatment decisions across various medical cases, thus supporting overall healthcare quality and regulatory compliance.