HEALTHCARE UTILIZATION REVIEW & MANAGED CARE CHECKLIST 2026

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--- PRE-AUTHORIZATION & PRIOR AUTHORIZATION VERIFICATION ---
[ ] Patient Identification Number
[ ] Payer/Insurance Carrier Name (Medicare, , Blue Cross Blue Shield, Aetna, UnitedHealthcare, Other Private Insurance)
[ ] Requested Service Date
[ ] Clinical Support Documentation
[ ] Authorization Status Check (Initial Request Submitted, Pending Payer Review, Approved, Denied, Request for Additional Information Sent)
[ ] Reviewer Verification Signature

--- MEDICAL NECESSITY & CLINICAL CRITERIA REVIEW ---
[ ] Clinical Criteria Standard Used (InterQual, MCG (Milliman Care Guidelines), Internal Facility Protocol, Other)
[ ] Required Clinical Evidence Present (Laboratory Results, Imaging Reports (X-Ray, CT, MRI), Physician Progress Notes, Vital Signs Trends, Diagnostic Test Results)
[ ] Justification for Acute Level of Care
[ ] Date of Clinical Review
[ ] Supporting Clinical Documentation
[ ] Reviewing Clinician Attestation

--- CONCURRENT REVIEW & INPATIENT MONITORING ---
[ ] Date of Review
[ ] Patient Acuity Level (Low, , High, Critical)
[ ] Current Level of Care Status
[ ] Clinical Review Tasks Completed (Physician Order Verification, Lab/Imaging Result Review, Nursing Note Assessment, Progression of Care Assessment)
[ ] Clinical Justification for Continued Stay
[ ] Reviewing Utilization Manager Signature

--- RETROSPECTIVE REVIEW & CLAIMS AUDIT ---
[ ] Audit Review Date
[ ] Patient Medical Record Number (MRN)
[ ] Review Type (Concurrent Review, Retrospective Review, Denial Appeal Review)
[ ] Discrepancies Identified (Coding Mismatch, Lack of Clinical Documentation, Incorrect Authorization Number, Inappropriate Level of Service)
[ ] Clinical Findings & Discrepancy Notes
[ ] Supporting Clinical Documentation
[ ] Auditor Verification Signature

--- DISCHARGE PLANNING & TRANSITION OF CARE ---
[ ] Discharge Disposition Type (Home with Home Health Services, Skilled Nursing Facility (SNF), Rehabilitation Center, Long-Term Acute Care Hospital (LTAC), Assisted Living, Home with Family Caregiver)
[ ] Target Discharge Date
[ ] Required Post-Discharge Services (Physical Therapy, Occupational Therapy, Speech Therapy, Wound Care, Home Oxygen Therapy, In-Home Nursing)
[ ] Follow-up Appointment Date & Time
[ ] Discharge Summary & Clinical Notes
[ ] Care Coordinator Verification

--- PAYER CONTRACT & MANAGED CARE AGREEMENT COMPLIANCE ---
[ ] Payer Organization Name (Medicare Advantage, Medicaid, Blue Cross Blue Shield, UnitedHealthcare, Aetna, Other Managed Care Entity)
[ ] Contract Effective Date
[ ] Contract Expiration/Renewal Date
[ ] Required Compliance Documents (Current Fee Schedule, Service Authorization Protocols, Network Participation Agreement, Credentialing Verification)
[ ] Upload Signed Agreement/Addendum
[ ] Specific Reimbursement Notes
[ ] Compliance Officer Verification

--- DENIAL MANAGEMENT & APPEALS DOCUMENTATION ---
[ ] Claim Reference Number
[ ] Denial Reason Category (Medical Necessity, Coding/Coding Error, Authorization Missing, Duplicate Claim, Timely Filing, Other)
[ ] Date of Denial Notification
[ ] Appeal Deadline Date
[ ] Root Cause Analysis Summary
[ ] Supporting Clinical Documentation
[ ] Reviewer/Auditor Attestation

--- UTILIZATION MANAGEMENT (UM) DATA REPORTING & ANALYTICS ---
[ ] Reporting Period End Date
[ ] Average Length of Stay (ALOS)
[ ] Total Denial Rate (%)
[ ] Primary Metric Focus (Readmission Rates, Denial Rate, Authorization Turnaround Time, Cost Per Case)
[ ] Key Performance Indicators (KPIs) Tracked (Avoidable Days, Denial Root Cause Analysis, Concurrent Review Completion, Payer Compliance Score)
[ ] Variance Analysis Summary
[ ] Monthly Utilization Report (PDF/CSV)
[ ] UM Director Review Authorization

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