Internal Utilization Management Escalation Path
Internal escalation guidance for utilization review and clinical decision support.
Clinical review escalation
Reviewers must follow the applicable criteria, document rationale, and meet decision timeframes. Escalate incomplete clinical information to the requesting provider, complex cases to the clinical lead, and potential compliance concerns to Compliance.
- Never disclose protected information through unapproved channels.
- Record peer-to-peer activity and determination rationale.
- Notify care management when a case presents coordination opportunity.