Critical Data Elements
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Defines the critical clinical and administrative data elements that must be recorded and considered when utilization review determinations are made for in-network and out-of-network programs and all provider types.
No material clinical or coverage changes in this revision.
Recording and Classification of Critical Data Elements
Requirement to record critical data elements
Recording requirement when adverse determinations are made
Applies across all in‑ and out‑of‑network programs and all provider types where utilization review determinations are performed.
Classified data elements
Categories of critical data elements used by reviewers
These four classified categories are used by Optum peer reviewers to inform utilization review decisions and documentation.
Actions, Documentation, and Applicability for Providers
Applicability to all programs and provider types
This policy applies to all in‑ and out‑of‑network programs and to all provider types for which utilization review determinations are performed; the listed critical data elements should inform utilization review decisions and documentation.
- Applies across all programs and provider types where utilization review is performed
Step therapy not defined in this policy
Not applicable. This policy defines categories of critical data elements used in utilization review and does not establish any step‑therapy sequencing or step requirements.
Record the specific critical data elements for adverse determinations
When an adverse clinical determination is rendered, the specific critical data elements that impacted the utilization review decision must be recorded. These elements include demographic and historical elements; nature of complaint/diagnosis; phase/plan/type/level of care and nature of condition; and patient‑reported measures, treatment goals and outcomes.
- Record which specific data elements influenced the adverse determination
- Include elements from all applicable categories listed in the policy
Risk if critical data elements are not recorded
Failure to record the critical data elements that impacted a utilization review decision when an adverse clinical determination is rendered can result in incomplete documentation of the basis for the determination and may affect the adequacy of the utilization review record.
- Ensure records explicitly state which critical data elements influenced the adverse decision
Key Definitions
Background on Utilization Management Policies
Utilization management policies are clinical criteria applied to individual patient presentations to reach utilization review determinations. Certain attributes of a clinical presentation—identified in this policy as critical data elements—significantly contribute to decision making and must be documented to explain utilization review outcomes.
This policy establishes that the critical data elements that impacted a particular utilization review decision will be recorded whenever an adverse clinical determination is rendered, and it defines the categories of data elements reviewers will consider when making and documenting utilization review determinations.
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