Health Utilization Management
URAC set the bar for health utilization management with the development of the first accreditation standards in this area in 1990. Our health utilization management standards are designed to ensure that organizations conducting utilization management follow a process that is clinically sound and respects patients’ and providers’ rights.
URAC’s accreditation program assures the adequacy and quality of your health utilization management process through evaluation against broadly recognized standards and measures. With URAC’s Health Utilization Management standards, organizations establish consistency and maintain the highest confidentiality in UM processes.
Designed to meet the demands of a changing healthcare system, URAC’s standards address the use of evidence-based guidelines, incorporation of adherence guidelines, and evaluation of utilization rates.
The URAC-accredited Health Utilization Management program:
- Provides an independent, unbiased determination of medical necessity beginning with an initial clinical review, then moving to a peer clinical review if needed
- Uses evidence-based treatment guidelines to enhance the quality and effectiveness of patient care while eliminating excessive treatment and expense
- Adheres to time frames outlined in the standards for urgent and non-urgent review determinations
- Understands and adheres to applicable state and federal regulations
- Employs drug utilization management mechanisms to address therapeutic appropriateness, over and underutilization, dosage, duration of treatment, duplication, drug allergies, and more
- Is prepared to address any risk to patient safety, such as contraindicated treatments, adverse drug interactions, or inappropriate treatment, during the review process
- And more.
The most widely recognized health utilization management standards at the state and federal level, URAC’s accreditation standards are applicable to stand-alone UM organizations and to UM functions within health benefits programs.
Earning the URAC Health Utilization Management Accreditation seal is a mark of distinction for organizations that demonstrate their commitment to quality and accountability.