CurrentLA Care HealthPolicy MMUM-013

USE, APPLICATION, AND DISCLOSURE OF UM CRITERIA AND INTERRATER RELIABILITY

Defines L.A. Care Health Plan's policies and procedures for establishing, applying, documenting, disclosing, and monitoring Utilization Management (UM) criteria including interrater reliability (IRR) testing, availability of criteria to providers/members, staff roles and authorities, and logging/reporting requirements across listed lines of business.

Policy Summary

PayerLA Care Health

PolicyUSE, APPLICATION, AND DISCLOSURE OF UM CRITERIA AND INTERRATER RELIABILITY

Policy CodePolicy MMUM-013

Change TypeAdministrative revisions (definitions, authorities, Attachment A review)

Effective DateDec 15, 2005

Next Review DateApr 9, 2027

Key ActionInclude the specific UM Criteria used in all approval, deferral, denial, modification, and termination determinations for authorization requests.

POLICY UPDATE CHANGES

Revision Date 1/13/2026: Reviewed criteria in Attachment A and added ASRM criteria to the PASC LOB; removed history over 10 years; added NCQA definition for IRR and DMHC APL 25-021 to authorities.

Change history includes prior updates adding NCQA-related provider involvement, IRR methodology, external consultants, public availability of criteria, and renaming Pre-Service to Prior Authorization per regulation.

>=90%Required IRR pass rate

Attachment AUM/BH Criteria location

AnnualMinimum review frequency

This administrative policy (MMUM-013) establishes the use of evidence‑based Utilization Management (UM) Criteria to guide utilization decisions, requires documentation of the specific UM Criteria used in all approval, deferral, denial, modification, and termination determinations, and defines procedures for logging requests for criteria and for making criteria available to providers, members, their representatives, and the public.

It assigns roles and authorities for UM staff and reviewers: non‑clinical UM Authorization Technicians for intake and level 1 approvals, clinical UM Nurse Specialists (RN/LVN) for clinical reviews and initial determinations with escalation of potential adverse actions to a Peer Reviewer, and requires that denials or limits in amount/duration/scope be made by a Qualified Health Care Professional with appropriate expertise.

The policy mandates Interrater Reliability (IRR) testing and related monitoring: IRR assessments for all clinical staff who make UM decisions, use of hypothetical test cases, annual submission of IRR results to the Utilization Management Committee (UMC), and maintenance of a minimum pass rate of 90% with two remediation attempts and additional remediation/supervision requirements if the threshold is not met.

L.A. Care must maintain current UMC‑approved UM/BH Criteria (Attachment A), make them publicly accessible (website) and notify providers about availability. Requests for criteria must be fulfilled following standard communication and privacy processes and include HSC §1363.5 disclosure language when provided to members and providers.

The policy requires ongoing monitoring and reporting: maintain a log of all requests for criteria, monitor compliance through UM auditing processes (MMUM‑002), and present IRR reporting and disclosure activity to the UM Committee and regulatory agencies as required. Criteria are reviewed at least annually and updated as needed.

Scope Metadata

Policy NumberMMUM-013

SubjectUse, application, and disclosure of Utilization Management (UM) criteria and interrater reliability

StatusCURRENT

Effective Date12/15/2005

Last Review04/08/2026

Next Review04/09/2027

Minimum review frequencyAnnual

Use of UM criteria and decision process

Use of UM Criteria / Decision Process

L.A. Care uses written Utilization Management (UM) Criteria based on sound clinical evidence to make utilization decisions. The Criteria are applied in a consistent, objective, and transparent manner and are available to providers and members upon request.

ALL of the following

Criteria are objective, transparent, consistent, and clinically valid and meet current medical guideline standards and practices.
Criteria are compatible with established principles of healthcare and flexible enough to allow deviation when justified on an individual case-by-case basis.
Criteria are used as screening Criteria to determine whether to approve the requested service and/or treatment.
Appropriate practitioners and external consultants (including physicians, pharmacists, and other qualified clinicians) are involved in developing, adopting, and reviewing the Criteria. The criteria and procedures for applying them are reviewed at least annually with involvement of actively practicing health care providers.
When applying Criteria to an individual Member, L.A. Care considers age, comorbidities, complications, progress of treatment, psychosocial needs, home environment when applicable, and avoids any practice that would delay or withhold care.
L.A. Care considers characteristics of the local delivery system for specific Members, including availability of contracted and non-contracted hospitals and specialists, availability of skilled nursing/sub-acute/home care and coverage of those benefits, and the local hospital's ability to provide recommended services within an estimated length of stay.
If approved UM Criteria do not meet a Member's medically necessary service needs, L.A. Care considers alternatives such as approving higher levels of care within the local area, arranging out-of-network or out-of-Plan services, consulting local or contracted physician consultants, or assembling panels of independent experts.
Availability, Disclosure and Requests for Criteria: L.A. Care maintains current versions of UMC-approved UM Criteria (see Attachment A) and posts applicable criteria (including UM/BH Clinical Criteria) on the public L.A. Care website. Criteria are available to providers and Members upon request and are updated annually or when changes are made.
Documentation, Logging and Monitoring: Requests for Criteria and requests to apply or review Criteria shall be logged, documented, and tracked. L.A. Care maintains processes to record requests for Criteria, the disposition of those requests, and any actions taken. UM staff (clinical and non-clinical) are trained on application of approved UM Criteria, and L.A. Care performs monitoring, quality assurance, and interrater reliability (IRR) testing per NCQA and internal requirements to ensure consistent application of Criteria.

Roles, authorities and escalation

Roles, Authorities and Escalation

Consistency and testing requirements for staff applying UM Criteria:

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Immediate Provider Actions (Callouts)

Note

Supporting Documentation Actions

Unsupported block type: instruction

Availability, disclosure and public access to criteria

Availability, Disclosure and Requests for Criteria: The following describes how L.A. Care makes Utilization Management (UM) and Behavioral Health (BH) criteria available to the public, to practitioners and Members, and how requests for criteria are fulfilled and logged.

ALL of the following

Public website availability: L.A. Care posts the current UM/BH approved criteria (see Attachment A) on its public website and updates them at least annually or when substantive changes are made.
Attachment A contains the maintained criteria hierarchy.
Disclosure to practitioners and Members: Upon request, L.A. Care will provide applicable UM/BH criteria to requesting practitioners and Members in a timely manner, including the rationale for any adverse determination and applicable coverage criteria.
Requests may be fulfilled electronically, by mail, or by phone per provider request.
Requests fulfillment and logging: L.A. Care will log all requests for UM criteria in a maintained log that records requester name, affiliation, date of request, criteria provided, and method of delivery. The log is retained to demonstrate compliance with disclosure obligations.
Provider actions require maintaining the log of criteria requests.
Adverse determinations: Any adverse determination (denial or modification for medical necessity) will be made only by qualified personnel (Peers or appropriately licensed Qualified Health Care Professionals) as defined in this policy, and the criteria and clinical rationale for the adverse determination will be disclosed to the provider and Member upon request.
Adverse determinations are communicated following required notification language and timeframes.
Provider responsibilities: Providers must follow the Level 1 approval list and escalation process when submitting requests and, when requesting criteria, must specify preferred delivery method; L.A. Care will fulfill such requests in accordance with provider actions described elsewhere in this policy.
See provider_actions for steps to fulfill requests and required disclosure language.
None specified.
If no additional provider actions are specified for certain criteria, standard disclosure and request procedures apply.

Note

Where criteria are maintained and how requests are handled

L.A. Care maintains the UM/BH approved criteria in Attachment A and posts these criteria on the public website. Providers requesting criteria will have their requests fulfilled per established provider actions, including escalation per the Level 1 approval list when applicable.

Criteria maintained in Attachment A.
Criteria posted on public website and updated at least annually.

Availability — key facts

UM/BH Criteria locationAttachment A

Minimum review frequencyAnnual

Documentation, logging, monitoring and reporting

Documentation Required

Documentation and Logging of UM Criteria Use

Document the specific UM Criteria used for every approval, deferral, denial, modification, and termination determination for authorization requests. Maintain and log all requests for criteria. Compliance with documentation and logging is monitored through UM auditing processes per MMUM-002.

Include the specific UM Criteria used in all determinations (approval, deferral, denial, modification, termination).
Maintain a log of all requests for criteria for monitoring and reporting.
Monitoring and auditing of compliance is performed per MMUM-002.

Key definitions

Term	Definition
Interrater Reliability (IRR)
Extent to which two or more independent surveyors produce similar results when assessing whether the same requirement is met; level of confidence that similarly trained individuals would produce similar scores.
Peer
A physician, pharmacist, or non-physician doctoral level behavioral practitioner with a valid California license and competence to evaluate the specific clinical issue; only peers may deny or modify requests for medical necessity.
Qualified Health Care Professional
Licensed health care professional competent to evaluate specific clinical issues; may include nurses, physicians, pharmacists, social workers, psychotherapists, dieticians and behavioral health analysts.
UM Authorization Technician
Non-clinical staff who performs initial intake and may approve certain prior-authorizations under clinical oversight.
UM Nurse Specialist
RN or LVN performing clinical utilization review of prior authorization requests, able to approve certain cases but escalate potential adverse determinations to a Peer Reviewer.
Utilization Management (UM)
Process of evaluating and determining coverage for and appropriateness of medical care services and providing assistance to clinicians or patients to ensure appropriate use of resources.

Change history and revisions

01/13/2026revisionLatest

Reviewed Attachment A UM/BH criteria; added ASRM criteria to the PASC line of business; removed history entries older than 10 years; added NCQA definition for IRR and DMHC APL 25-021 to Authorities.

2016-2025administrative_updates

Prior administrative/process updates include annual reviews, addition of NCQA-related provider involvement and IRR methodology (2016–2025), updates for external consultants and physician-administered drugs, public availability of criteria on the website, renaming Pre-Service to Prior Authorization per regulation, and other template/formatting and regulatory authority changes.