Do UR policies and procedures and a description of the process have to be filed with the administrative director?

Do UR policies and procedures and a description of the process have to be filed with the administrative director?

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

Answer: (B)

Utilization review relies on documented procedures to ensure medical necessity determinations are made consistently and transparently. In California, the self‑insured plan must have its UR policies and procedures and a description of the process on file with the Administrative Director so the state can oversee that the program is implemented properly, timelines are followed, and the rights to appeal are clear. Because oversight and compliance are ongoing, these materials must be filed rather than only being available on request or only in disputes. If they aren’t filed, the plan isn’t meeting regulatory requirements and could lose approval to operate its UR program or face penalties.

Utilization review relies on documented procedures to ensure medical necessity determinations are made consistently and transparently. In California, the self‑insured plan must have its UR policies and procedures and a description of the process on file with the Administrative Director so the state can oversee that the program is implemented properly, timelines are followed, and the rights to appeal are clear.

Because oversight and compliance are ongoing, these materials must be filed rather than only being available on request or only in disputes. If they aren’t filed, the plan isn’t meeting regulatory requirements and could lose approval to operate its UR program or face penalties.