Do UR Policies and Procedures and a description of the process have to be filed with the Administrative Director?

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

Answer: (A)

Utilization review activities for California self‑insured plans are regulated and overseen by the Administrative Director. Having the UR policies and procedures, along with a description of how the process operates, filed with the Administrative Director allows the director to review and verify that the plan’s UR program complies with applicable laws, standards, and timelines. This oversight helps ensure medical necessity determinations are made consistently, independently where required, and within the required timeframes, and it provides a clear framework for how UR decisions will be conducted and reviewed.

Because of this oversight role, these documents aren’t optional or contingent on a request or a dispute. They must be filed so the Administrative Director can approve and monitor the program. If these are not filed, the plan would be out of compliance with the regulatory requirements governing UR for self‑insured plans.